Non-muscle-invasive bladder cancer

Diagnosis

Healthcare professionals diagnose bladder cancer by looking inside the bladder and testing tumor tissue. They also may use urine tests and imaging tests.

Cystoscopy

Cystoscopy uses a thin tube with a light and lens to look inside the bladder and the tube that carries urine out of the body, called the urethra. Cystoscopy is the main test used to look for bladder tumors.

Urine tests

A urine cytology test checks a urine sample for cancer cells. Urine cytology is better for finding high-grade tumors, including CIS, than for finding low-grade tumors.

Imaging

A computerized tomography (CT) urogram can make pictures of the kidneys, ureters and bladder. Imaging also can help with staging when a cancer may be high grade or invasive.

Transurethral resection of bladder tumor

If you have a tumor, a procedure called transurethral resection of bladder tumor (TURBT) can remove the visible tumor through the urethra. The tissue is then tested to find the tumor's grade and how deeply it has grown into the bladder lining.

Sometimes, you may need a second TURBT. This may happen if the first procedure was not complete or for some high-grade tumors, especially T1 disease.

Grades

Grade describes how cancer cells look under a microscope. It also gives clues about how the cancer may act. NMIBC is usually described as low grade or high grade.

• Low-grade cancers. These cancers often come back after treatment. But they rarely grow into the bladder muscle or spread to other parts of the body.
• High-grade cancers. These cancers are more likely to come back, grow into the bladder muscle and spread. CIS is high grade.

Treatment

Treatment depends on more than the grade and stage. Your healthcare team also looks at the number and size of tumors and whether CIS is present. Together, these features help place NMIBC into a risk group. Risk groups help guide treatment and follow-up.

Risk groups

• Low-risk NMIBC. This group usually includes a small, single, low-grade Ta tumor.
• Intermediate-risk NMIBC. This group has features between low and high risk, such as having several tumors or cancer that has come back.
• High-risk NMIBC. This group includes cancers more likely to progress, such as CIS or high-grade T1 disease.

Risk groups are not the same as cancer stages. Risk groups use stage, grade and other tumor features to estimate the chance that NMIBC will come back or progress.

Transurethral resection of bladder tumor

TURBT is the first treatment for most visible NMIBC tumors. The surgeon removes as much of the visible tumor as possible through the urethra. The tissue is tested to confirm stage and grade.

Intravesical chemotherapy

Intravesical treatment puts medicine directly into the bladder through a thin tube called a catheter. Chemotherapy given this way can lower the chance that cancer will come back, especially for low- and intermediate-risk disease.

BCG immunotherapy

Bacillus Calmette-Guerin (BCG) is an immunotherapy put directly into the bladder. It helps the immune system attack bladder cancer cells. BCG is a standard treatment for many intermediate- and high-risk NMIBCs.

For high-risk NMIBC, BCG often is given as a first course followed by maintenance treatment. Maintenance may last 1 to 3 years depending on your risk and treatment plan.

Some people with high- or very-high-risk NMIBC who have not had BCG before may receive durvalumab, a type of immunotherapy. It is added to BCG with maintenance. More study is needed to understand its long-term benefits and risks.

When BCG does not work

If high-risk NMIBC comes back after BCG treatment, the care team considers how much BCG you received, when the cancer came back and how it responded to treatment. These factors help guide the next treatment recommendation. High-grade cancer that comes back within set time periods after enough BCG treatment may be called BCG-unresponsive NMIBC.

For many people, removing the bladder with radical cystectomy is the preferred treatment. Bladder-preserving treatments and clinical trials may be options for people who cannot have or do not want cystectomy.

Bladder-preserving choices include medicines put into the bladder and, sometimes, immunotherapy given through the bloodstream. Nadofaragene firadenovec (Adstiladrin) is a gene therapy put directly into the bladder. Pembrolizumab is an immunotherapy that may be used for some people with high-risk BCG-unresponsive NMIBC.

Cystectomy

Radical cystectomy is surgery to remove the bladder. It may be recommended for very-high-risk NMIBC or high-grade disease that does not respond to BCG. The decision weighs the risk of cancer progression against the risks and effects of major surgery.

Follow-up and surveillance

NMIBC often comes back, so follow-up after treatment is important. The first follow-up cystoscopy is typically done three months after TURBT for people with Ta, T1 or CIS.

After that, the timing of follow-up depends on the person's risk group. People who have high-risk disease need closer and longer follow-up than do those with low-risk disease.

Follow-up may include cystoscopy, urine cytology and imaging of the upper urinary tract. Which tests are used depends on risk.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Preparing for your appointment

Make an appointment with a healthcare professional if you have any symptoms that worry you. You likely will start by seeing your primary care team. But you might be referred to a doctor who specializes in treating diseases and conditions of the urinary tract, called a urologist. Sometimes, you may be referred to other specialists, such as a doctor who treats cancer, called an oncologist. Here are some tips to get ready for your appointment.

What you can do

When you make the appointment, ask if there's anything you need to do before your appointment, such as not eating or drinking for a certain amount of time. Make a list of:

• Your symptoms, including any that don't seem related to the reason for your appointment.
• Key personal information, including major stresses, recent life changes and family medical history.
• All medicines, vitamins and other supplements you take, including the doses.
• Questions to ask your healthcare professional.

Take a family member, friend or another trusted person with you, if possible, to help you remember the information you get.

For bladder cancer, basic questions to ask your healthcare professional include:

• Do I have bladder cancer, or could my symptoms be caused by another condition?
• What tests do I need?
• What is the stage of my cancer?
• What are my treatment options?
• What treatments might cure bladder cancer?
• What are the possible risks of each treatment?
• Should I see a specialist?
• Is there a generic alternative to the medicine you're prescribing?
• Do I need follow-up appointments?
• Are there brochures or other printed material that I can take with me? What websites do you recommend?

Be sure to ask any other questions you may have.

What to expect from your care team

Your healthcare professional is likely to ask you questions, such as:

• When did your symptoms start?
• Are your symptoms always present, or do they come and go?
• How bad are your symptoms?
• What, if anything, makes your symptoms better?
• What, if anything, makes your symptoms worse?