Diagnosing bladder cancer
Tests and procedures used to diagnose bladder cancer may include:
- Cystoscopy. To perform cystoscopy, your doctor inserts a small, narrow tube (cystoscope) through the urethra. The cystoscope has a lens that allows your doctor to see the inside of your urethra and bladder, to examine these structures for signs of disease.
- Biopsy. During cystoscopy, your doctor may pass a special tool through the scope and into your bladder to collect a cell sample (biopsy) for testing. This procedure is sometimes called transurethral resection of bladder tumor (TURBT). TURBT can also be used to treat bladder cancer.
- Urine cytology. A sample of your urine is analyzed under a microscope to check for cancer cells in a procedure called urine cytology.
Imaging tests. Imaging tests, such as computerized tomography (CT) urogram or retrograde pyelogram, allow your doctor to examine the structures of your urinary tract.
During a CT urogram, a contrast dye injected into a vein in your hand eventually flows into your kidneys, ureters and bladder. X-ray images taken during the test provide a detailed view of your urinary tract and help your doctor identify any areas that might be cancer.
Retrograde pyelogram is an X-ray exam used to get a detailed look at the upper urinary tract. During this test, your doctor threads a thin tube (catheter) through your urethra and into your bladder to inject contrast dye into your ureters. The dye then flows into your kidneys while X-ray images are captured.
Determining the extent of the cancer
After confirming that you have bladder cancer, your doctor may recommend additional tests to determine whether your cancer has spread to your lymph nodes or to other areas of your body.
Tests may include:
- CT scan
- Magnetic resonance imaging (MRI)
- Bone scan
- Chest X-ray
Your doctor uses information from these procedures to assign your cancer a stage. The stages of bladder cancer are indicated by Roman numerals ranging from 0 to IV. The lowest stages indicate a cancer that's confined to the inner layers of the bladder and that hasn't grown to affect the muscular bladder wall. The highest stage — stage IV — indicates cancer has spread to lymph nodes or organs in distant areas of the body.
The cancer staging system continues to evolve and is becoming more complex as doctors improve cancer diagnosis and treatment. Your doctor uses your cancer stage to select the treatments that are right for you.
Bladder cancer grade
Bladder cancer tumors are further classified based on how the cancer cells appear when viewed through a microscope. This is known as tumor grade, and your doctor may describe bladder cancer as either low grade or high grade:
- Low-grade bladder tumor. This type of tumor has cells that are closer in appearance and organization to normal cells (well-differentiated). A low-grade tumor usually grows more slowly and is less likely to invade the muscular wall of the bladder than is a high-grade tumor.
- High-grade bladder tumor. This type of tumor has cells that are abnormal-looking and that lack any resemblance to normal-appearing tissues (poorly differentiated). A high-grade tumor tends to grow more aggressively than a low-grade tumor and may be more likely to spread to the muscular wall of the bladder and other tissues and organs.
Treatment options for bladder cancer depend on a number of factors, including the type of cancer, grade of the cancer and stage of the cancer, which are taken into consideration along with your overall health and your treatment preferences.
Bladder cancer treatment may include:
- Surgery, to remove cancerous tissue
- Chemotherapy in the bladder (intravesical chemotherapy), to treat tumors that are confined to the lining of the bladder but have a high risk of recurrence or progression to a higher stage
- Reconstruction, to create a new way for urine to exit the body after bladder removal
- Chemotherapy for the whole body (systemic chemotherapy), to increase the chance for a cure in a person having surgery to remove the bladder, or as a primary treatment in cases where surgery isn't an option
- Radiation therapy, to destroy cancer cells, often as a primary treatment in cases where surgery isn't an option or isn't desired
- Immunotherapy, to trigger the body's immune system to fight cancer cells, either in the bladder or throughout the body
A combination of treatment approaches may be recommended by your doctor and members of your care team.
Bladder cancer surgery
Approaches to bladder cancer surgery might include:
Transurethral resection of bladder tumor (TURBT). TURBT is a procedure to remove bladder cancers confined to the inner layers of the bladder, those which aren't yet muscle-invasive cancers. During the procedure, a surgeon passes a small wire loop through a cystoscope and into the bladder. The wire loop burns away cancer cells using an electric current. Alternatively, a high-energy laser may be used to destroy the cancer cells.
TURBT is performed under regional anesthesia — where medication given numbs only the lower part of your body — or general anesthesia — where medication puts you to sleep during the surgery. Because doctors perform the procedure through the urethra, you won't have any cuts (incisions) in your abdomen.
As part of the TURBT procedure, your doctor may recommend a one-time injection of cancer-killing medication (chemotherapy) into your bladder to destroy any remaining cancer cells and to prevent a tumor from coming back. The medication remains in your bladder for up to an hour and then is drained.
Cystectomy. Cystectomy is surgery to remove all or part of the bladder. During a partial cystectomy, your surgeon removes only the portion of the bladder that contains a single cancerous tumor. Partial cystectomy may only be an option if cancer is limited to one area of the bladder that can easily be removed without harming bladder function.
A radical cystectomy is an operation to remove the entire bladder, part of the ureters and surrounding lymph nodes. In men, radical cystectomy typically includes removal of the prostate and seminal vesicles. In women, radical cystectomy also involves removal of the uterus, ovaries and part of the vagina.
Radical cystectomy can be performed through a single incision on the lower portion of the belly or with multiple small incisions using robotic surgery. During robotic surgery, the surgeon sits at a nearby console and uses hand controls to precisely move robotic surgical instruments.
Cystectomy carries a risk of infection and bleeding. In men, removal of the prostate and seminal vesicles may cause erectile dysfunction. But, your surgeon may be able to spare the nerves necessary for an erection. In women, removal of the ovaries causes infertility and premature menopause.
- Neobladder reconstruction. After a radical cystectomy, your surgeon must create a new way for urine to leave your body (urinary diversion). One option for urinary diversion is neobladder reconstruction. Your surgeon creates a sphere-shaped reservoir out of a piece of your intestine. This reservoir, often called a neobladder, sits inside your body and is attached to your urethra. In most cases, the neobladder allows you to urinate normally. A small number of people with a neobladder have difficulty emptying the neobladder and may need to use a catheter periodically to drain all the urine from the neobladder.
- Ileal conduit. For this type of urinary diversion, your surgeon creates a tube (ileal conduit) using a piece of your intestine. The tube runs from your ureters, which drain your kidneys, to the outside of your body, where urine empties into a pouch (urostomy bag) you wear on your abdomen.
- Continent urinary reservoir. During this type of urinary diversion procedure, your surgeon uses a section of intestine to create a small pouch (reservoir) to hold urine, located inside your body. You drain urine from the reservoir through an opening in your abdomen using a catheter a few times each day.
Chemotherapy uses drugs to kill cancer cells. Chemotherapy treatment for bladder cancer usually involves two or more chemotherapy drugs used in combination.
Chemotherapy drugs can be given:
- Through a vein in your arm (intravenously)
- Via a tube passed through your urethra directly to your bladder (intravesical therapy)
Chemotherapy is frequently used before bladder removal surgery to increase the chances of curing the cancer. Chemotherapy may also be used to kill cancer cells that might remain after surgery. Chemotherapy is sometimes combined with radiation therapy in very select cases as an alternative to surgery.
Intravesical chemotherapy may be the primary treatment for superficial bladder cancer, where the cancer cells affect only the lining of the bladder and not the deeper muscle tissue. Or sometimes immunotherapy may be administered as intravesical therapy for superficial bladder cancer.
Radiation therapy uses high-energy beams aimed at your cancer to destroy the cancer cells. Radiation therapy for bladder cancer usually is delivered from a machine that moves around your body, directing the energy beams to precise points.
In select cases, radiation therapy is sometimes combined with chemotherapy as an alternative to surgery or when surgery isn't an option.
Immunotherapy, also called biological therapy, works by signaling your body's immune system to help fight cancer cells.
Immunotherapy for bladder cancer often is administered through the urethra and directly into the bladder (intravesical therapy). One such immunotherapy drug used to treat bladder cancer is Bacillus Calmette-Guerin (BCG), which is a vaccine used to protect against tuberculosis. Another immunotherapy drug is a synthetic version of interferon, which is a protein your immune system makes to help fight infections. The synthetic version, called interferon alfa-2b (Intron A), is sometimes used in combination with BCG.
Atezolizumab (Tecentriq) is a new immunotherapy option for locally advanced or metastatic bladder cancer that didn't respond to or got worse after chemotherapy. An intravenous (IV) medication, the drug works by triggering the body's immune system to attack the cancerous tumor. Atezolizumab is also being studied as a possible first line therapy for people with bladder cancer who aren't eligible for chemotherapy.
Using a three-prong treatment approach may preserve the bladder in certain cases of muscle-invasive disease. Known as trimodality therapy, the treatment approach includes TURBT, chemotherapy and radiation therapy.
First, your surgeon performs a TURBT procedure to remove as much cancerous tissue as possible from your bladder, while maintaining bladder function. After TURBT, you undergo a regimen of chemotherapy along with radiation therapy, which both take place during the first several weeks after surgery.
If, after trying trimodality therapy, not all of the cancer is gone or you have a recurrence of muscle-invasive cancer, your surgeon may recommend a radical cystectomy.
Upper urinary tract disease
The same kind of cancer (urothelial cancer) that causes the majority of bladder cancers can also occur in the upper urinary tract, affecting:
- The thin tubes that drain urine from your kidneys to your bladder (ureters)
- The area within your kidney where urine collects before emptying into a ureter (renal pelvis)
- Other urinary tract structures deep within the kidney where the process of producing urine begins
Similar to treatment for bladder cancer, treatment of upper urinary tract cancer depends on a lot of factors, such as tumor size, tumor location, your overall health and your preferences.
Upper urinary tract cancer generally involves surgery to remove the cancer, along with chemotherapy or radiation therapy as follow-up treatments to kill any remaining cancer cells and to prevent recurrence.
Surgery might leave you with only one functioning kidney, if one of your kidneys needs to be removed. If that happens, your doctor will likely recommend regular testing of your kidney function to monitor how well your remaining kidney is doing.
After bladder cancer treatment
Bladder cancer may recur. Because of this, people with bladder cancer need follow-up testing for years after successful treatment. What tests you'll have and how often depends on your type of bladder cancer and how it was treated, among other factors.
Ask your doctor to create a follow-up plan for you. In general, doctors recommend a test to examine the inside of your urethra and bladder (cystoscopy) every three to six months for the first few years after bladder cancer treatment. After a few years of surveillance without detecting cancer recurrence, you may need a cystoscopy exam only once a year. Your doctor may recommend other tests at regular intervals as well.
People with aggressive cancers may undergo more-frequent testing. Those with less aggressive cancers may undergo testing less often.
Coping and support
Living with the concern that your bladder cancer may recur can leave you feeling as if you have little control over your future. But while there's no way to ensure that your bladder cancer won't recur, you can take steps to manage the stress.
Over time you'll find what works for you, but until then, you might:
- Have a schedule of follow-up tests and go to each appointment. When you finish bladder cancer treatment, ask your doctor to create a personalized schedule of follow-up tests. Before each follow-up cystoscopy exam, expect to have some anxiety. You may fear that cancer has come back or worry about the uncomfortable exam. But don't let this stop you from going to your appointment. Instead, plan ways to cope with your concerns. Write your thoughts in a journal, talk with a friend or use relaxation techniques, such as meditation.
- Take care of yourself so that you're ready to fight cancer if it comes back. Take care of yourself by adjusting your diet to include plenty of fruits, vegetables and whole grains. Exercise for at least 30 minutes most days of the week. Get enough sleep so that you wake feeling rested.
- Talk with other bladder cancer survivors. Connect with bladder cancer survivors who are experiencing the same fears you're feeling. Contact your local chapter of the American Cancer Society to ask about support groups in your area.
Preparing for your appointment
Start by seeing your family doctor or a primary doctor if you have any signs or symptoms that worry you. Your doctor may suggest tests and procedures to investigate your signs and symptoms.
If your doctor suspects you may have bladder cancer, you may be referred to a doctor who specializes in treating diseases and conditions of the urinary tract (urologist). In some cases, you may be referred to other specialists, such as doctors who treat cancer (oncologists).
Because there's often a lot of ground to cover during the appointment, it's a good idea to be well-prepared. Here's some information to help you get ready, and what to expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do in advance, such as restrict your diet.
- Write down any symptoms you're experiencing, including any that seem unrelated to the reason for which you scheduled the appointment.
- Write down key personal information, including any major stresses or recent life changes.
- Make a list of all medications, vitamins or supplements that you're taking along with dosages.
- Consider taking a family member or friend along. Sometimes, it's difficult to remember all of the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor.
Preparing a list of questions can help you make the most of your time with your doctor. For bladder cancer, some basic questions to ask include:
- Do I have bladder cancer or could my symptoms be caused by another condition?
- What is the stage of my cancer?
- Will I need any additional tests?
- What are my treatment options?
- Can any treatments cure my bladder cancer?
- What are the potential risks of each treatment?
- Is there one treatment you feel is best for me?
- Should I see a specialist? What will that cost, and will my insurance cover it?
- Is there a generic alternative to the medicine you're prescribing me?
- Are there brochures or other printed material that I can take with me? What websites do you recommend?
- What will determine whether I should plan for a follow-up visit?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions that occur to you.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may allow time later to cover other points you want to address. Your doctor may ask:
- When did you first begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?