Bladder cancer

The bladder is part of the body’s urinary system. It stores urine and gets rid of it when you go to the toilet. Bladder cancer begins when cells inside the bladder change and grow out of control.

Most people diagnosed with bladder cancer are 60 years or older, but it can occur at any age. It is one of the more common cancers in men.

Signs and symptoms#

Sometimes bladder cancer does not cause many symptoms. When signs do appear, they can include:

• blood in your urine
• needing to urinate often or urgently
• pain or burning when passing urine
• not being able to pass urine when you need to

Less commonly, people may have pain on one side of their lower abdomen (belly) or back, lose their appetite or lose weight.

Not everyone with these symptoms has bladder cancer, but if you have any of them or are worried, always see your doctor.

Risk factors#

Some things can make bladder cancer more likely. Having one or more does not mean you will get it, and often there is no clear reason why bladder cancer develops. Risk factors include:

• Smoking – people who smoke are up to 3 times more likely than non-smokers to develop bladder cancer.
• Age – about 90% of people diagnosed with bladder cancer are aged over 60.
• Being male – men are around 3 times more likely than women to develop bladder cancer.
• Chemical exposure at work – chemicals called aromatic amines, benzene products and aniline dyes are linked to bladder cancer. They are used in rubber and plastics manufacturing and the dye industry, and may be encountered by painters, machinists, printers, hairdressers, firefighters and truck drivers.
• Parasitic bladder infection – a rarer type of bladder cancer (squamous cell carcinoma) has been linked to schistosomiasis, an infection caused by a parasite found in fresh water in parts of Africa, Asia, South America and the Caribbean. This type is uncommon in many countries.
• Long-term catheter use.
• Previous cancer treatments – some types of radiation therapy around the pelvis, and the chemotherapy drug cyclophosphamide.
• Diabetes treatment – the diabetes drug pioglitazone can increase the risk of bladder cancer.
• Personal or family history – most people with bladder cancer do not have a family history, but having one or more close blood relatives with bladder cancer, or an inherited gene linked to it, slightly increases the risk.

If you are worried about your risk factors, ask your doctor for advice.

Tests for bladder cancer#

Your doctor may carry out a number of tests to check for bladder cancer:

• internal examination – the doctor may check inside your bottom or vagina with a gloved finger
• urine tests – to look for signs of bladder cancer
• blood tests – to check your general health
• ultrasound – a scan on the outside of your abdomen
• CT scan and x-rays – sometimes called a CT-IVP or a triple-phase abdominal-pelvic CT scan
• MRI scan – uses magnetism and radio waves to take pictures inside the body
• cystoscopy – the doctor puts a small camera into your bladder to see inside
• biopsy – a small sample of cells is taken from the bladder to check for cancer
• transurethral resection of bladder tumour (TURBT) – the doctor removes or destroys the tumour
• bone scan and PET-CT scan – further scans your doctor may request

Types of bladder cancer#

Bladder cancer can be described by where it is found:

• Superficial (non-muscle invasive) – the cancer has not spread to other layers of the bladder or muscle.
• Muscle-invasive – the cancer has spread into the muscle layer or to other parts of the body.

There are three main types:

• Urothelial carcinoma – 80 to 90% of bladder cancers, sometimes called transitional cell carcinoma.
• Squamous cell carcinoma – 1 to 2% of bladder cancers, and more likely to be invasive (to spread).
• Adenocarcinoma – about 1% of bladder cancers, also more likely to be invasive.

There are other, less common types, and treatment for these may be different. Speak to your doctor or nurse for information about them.

Stages and grades#

Stages and grades describe how far a cancer has spread and how quickly it is growing.

The stage describes how far the cancer has grown. The most common system is the TNM system (tumour, nodes, metastasis), which describes how far the tumour has grown into the bladder wall and nearby tissues, whether it has spread to nearby lymph nodes, and whether it has spread to other parts of the body. Some doctors combine the TNM scores into an overall stage, from stage 1 (earliest) to stage 4 (most advanced). Ask your doctor or nurse to explain the stage of your cancer.

The grade describes how quickly a cancer might grow:

• Low grade – the cells are usually slow-growing. Most bladder tumours are low grade.
• High grade – the cells look very abnormal and grow quickly, and are more likely to spread. Almost all muscle-invasive cancers are high grade.

Note: bladder carcinoma in situ is an early-stage cancer but is always high grade, which means it can grow quickly and may spread. If you have it, your doctor will start treatment straight away, and treatment can be very effective.

Prognosis#

When someone is diagnosed, their doctor will give a prognosis, which is the doctor’s opinion of how likely the cancer is to spread and the chances of recovery. It depends on the type and stage of the cancer, as well as your age and general health.

Bladder cancer can usually be treated effectively if it is found before it spreads outside the bladder. Your doctor will discuss your individual situation. Every person’s experience is different, and there is support available to you.

Treatment#

Treatment depends on how quickly the cancer is growing and differs for non-muscle-invasive and muscle-invasive bladder cancer. You might feel confused or unsure about your options. It is okay to ask your treatment team to explain things more than once, and to take time over your decisions. You may want to discuss your options with a urologist, radiation oncologist and medical oncologist, so ask your doctor for referrals.

Treatment for superficial bladder cancer#

Most people with superficial bladder cancer have an operation to remove the cancer, most commonly a TURBT (transurethral resection of bladder tumour). Sometimes a second TURBT or different surgery is needed. Because the cancer can come back after surgery, you will need regular follow-up tests so that treatment can start again if needed.

Other treatments include:

• Intravesical chemotherapy – medication put directly into the bladder through a tube (catheter) to destroy or slow cancer cells while causing the least possible harm to healthy cells. It is used only for non-muscle-invasive cancer to help stop it coming back. You may have one dose or more.
• Intravesical immunotherapy – uses Bacillus Calmette-Guérin (BCG) placed directly into the bladder through a catheter to stop or slow the cancer. A combination of BCG and TURBT is most effective. BCG is usually given once a week for 6 weeks, starting 2 to 4 weeks after TURBT. This may happen in a hospital or clinic, and may be repeated depending on your response.

Treatment for muscle-invasive bladder cancer#

When bladder cancer has invaded the muscle layer, the main options are:

• surgery to remove the whole bladder (cystectomy), sometimes with chemotherapy before or after surgery
• bladder-conserving surgery (TURBT) followed by radiation therapy, with or without chemotherapy (trimodal therapy)

Surgery (cystectomy). The surgeon usually needs to remove the whole bladder (radical cystectomy).

Systemic chemotherapy. For muscle-invasive cancer, chemotherapy is injected into a vein. It may be given before surgery to shrink the cancer (neoadjuvant), after surgery if there is a high risk of it returning (adjuvant), or to treat cancer that has spread. It is given as a course at regular intervals over several months.

Radiation therapy uses a controlled dose of radiation, usually as x-ray beams, to kill or damage cancer cells. It is used as part of trimodal therapy, either on its own or with chemotherapy.

Trimodal therapy may be the main treatment for muscle-invasive tumours, especially if you cannot have surgery to remove the bladder or would prefer to keep it. It suits people whose bladder works well and who have smaller tumours that have not spread. It involves a shorter surgery to remove the tumour (TURBT), followed by radiation therapy combined with chemotherapy (chemoradiation); the chemotherapy makes the cancer cells more sensitive to radiation. Some people who are not fit enough for chemotherapy have radiation therapy alone. Ask your medical team whether it may be an option for you.

Treatment for advanced bladder cancer#

If bladder cancer has spread to other parts of the body, it is known as advanced or metastatic bladder cancer. You may be offered one or a combination of treatments to control the cancer and ease symptoms, including systemic chemotherapy, radiation therapy, surgery and immunotherapy.

Immunotherapy uses the body’s own immune system to fight cancer. BCG has been used for many years to treat superficial bladder cancer. A newer group of immunotherapy drugs called checkpoint inhibitors help the immune system recognise and attack the cancer. After a course of chemotherapy, some people with advanced bladder cancer have checkpoint inhibitor drugs such as pembrolizumab or avelumab. These are given into a vein through a drip (infusion), repeated every 2 to 6 weeks, with the number of infusions depending on how you respond.

Side effects and preparing for treatment#

All cancer treatments can have side effects. Your treatment team will discuss these before you start, and you should tell your doctor or nurse about any you experience. Some side effects can be upsetting, but help is available.

To prepare for treatment and aid recovery, your team may suggest:

• Stop smoking – if you smoke, aim to quit before treatment. Continuing to smoke can make treatment less effective, cause more side effects and increase the risk of the cancer returning.
• Exercise – this builds strength for treatment and recovery and helps you cope with side effects.
• Improve your diet – aim for a balanced diet with a variety of fruit, vegetables, wholegrains and protein, which can improve your strength and how well you respond to treatment.
• See a physiotherapist – they can teach pelvic floor exercises that help control the bladder and bowel, which are useful if you have a neobladder, a partial cystectomy or radiation therapy.
• Talk to someone – a psychologist or counsellor can help with anxiety about surgery and with longer-term changes after treatment.

Bladder reconstruction and stomas#

If your bladder is removed, the way you pass urine will change. Your treatment team will talk you through the options:

• Urostomy (ileal conduit) – a new opening (stoma) is created in your abdomen, and urine drains into a special bag on the outside.
• Neobladder – a new bladder made from your small bowel forms a pouch inside your body. You pass urine by squeezing your abdominal muscles, and pass a small catheter into the pouch each day to help drain it.
• Continent urinary diversion – a pouch made from your small bowel stores urine inside your body, emptying through a stoma into a special bag.

A bladder reconstruction is a big change. You can speak with a continence or stomal therapy nurse for help, support and information, and a trained volunteer who has had cancer may be able to share tips and support. If you find it hard to adjust, a referral to a psychologist or counsellor may help, and if you have a stoma you can join a stoma association for support and supplies.

Sexuality, fertility and bladder cancer#

Having bladder cancer and treatment can change the way you feel about yourself, other people, relationships and sex. These changes can be very upsetting and hard to talk about, but doctors and nurses are understanding and can give you support. You can ask for a referral to a counsellor or therapist who specialises in body image, sex and relationships.

• Changes for men after a cystectomy may include damaged nerves to the penis, changes to orgasm, and effects on fertility.
• Changes for women after a cystectomy may include vaginal narrowing, shortening or dryness, changes to sexual arousal and orgasm, and menopause and fertility.

If you may want to have children in the future, talk to your treatment team before starting treatment.

Living with advanced cancer#

Advanced cancer usually means cancer that is unlikely to be cured, but some people live for many months or years with it. During this time, palliative care services can help. Most people continue to have treatment for advanced cancer as part of palliative care, because it helps manage the cancer and improve day-to-day life.

Many people think palliative care is only for those who are dying, but it is for any stage of advanced cancer. Specialist doctors, nurses and others can help you live more comfortably by managing symptoms such as pain. Treatment may include chemotherapy, radiation therapy or other approaches, and depends on how far the cancer has spread, your general health and your own preferences.

Support for carers, family and friends#

Caring for someone with cancer can be difficult. If you are caring for someone with bladder cancer, support services can help you find the information, resources and support you may need following a diagnosis.

Key points#

• Bladder cancer is most common in people over 60 and is more common in men.
• Blood in the urine, changes in urination, and pain or burning when passing urine can be signs, so see your doctor if you notice them.
• Smoking, age, chemical exposure at work and some medical treatments are among the risk factors.
• Treatment depends on whether the cancer is superficial or muscle-invasive and may include surgery, chemotherapy, immunotherapy and radiation therapy.
• Bladder cancer can usually be treated effectively if found before it spreads, and support is available for you and your carers.

Where to get help#