Bladder Cancer

The bladder wall is made up of several layers, which are composed of different types of cells. Most cancers start in the inner lining of the wall. As cancer grows, it can spread through the layers of the wall and may spread beyond the bladder.

According to the American Cancer Society, bladder cancers may be described as invasive or non-invasive based on whether they have spread into the bladder wall:

• Non-invasive cancers are in the inner layer of cells (the transitional epithelium), but have not grown into the deeper layers.
• Invasive cancers have grown into deeper layers of the bladder wall. These cancers are more likely to spread and are harder to treat.

There are two subtypes of bladder cancer:

• Papillary carcinomas grow in slender, finger-like projections from the inner surface of the bladder toward the hollow center. Papillary tumors that grow toward the center of the bladder without growing into the deeper bladder layers are called non-invasive papillary cancers. 
• Flat carcinomas do not grow toward the hollow part of the bladder. A flat tumor that is only in the inner layer of bladder cells is known as a non-invasive flat carcinoma or a flat carcinoma in situ (CIS).

Urothelial carcinoma

A papillary or flat tumor that grows into deeper layers of the bladder is called an invasive urothelial (or transitional cell) carcinoma. Almost all bladder cancers are this type. Other types are very rare.

Squamous cell carcinoma

Squamous cell carcinomas make up less than 2% of bladder cancers in the U.S. This rare cancer type is usually invasive.

Adenocarcinoma

Adenocarcinomas represent about 1% of bladder cancers, and are nearly always invasive.

Small cell carcinoma

Small cell carcinomas, which start in neuroendocrine cells, make up less than 1% of bladder cancers. They typically grow quickly and are treated with chemotherapy.

Sarcomas

Sarcomas are a rare bladder cancer type that start in the muscle cells.

All of the causes of bladder cancer are not known. But according to the American Cancer Society, researchers do know that some cases are related to gene mutations that occur during a person’s lifetime (rather than being inherited). Some of these mutations are related to exposure to cancer-causing substances, such as those in tobacco smoke or workplace chemicals. Other mutations have unknown causes. 

Known bladder cancer risk factors include:

Tobacco use

Smoking is the most important risk factor for bladder cancer. Smokers have about three times the risk of developing bladder cancer compared to non-smokers. This include cigarettes, pipes and cigars.

Exposure to workplace chemicals

Certain industrial chemicals called aromatic amines and other organic chemicals (especially those used in dyes, paint, rubber, textiles, dry cleaning and diesel fuel) have been linked to bladder cancer.

Gender

Men have up to four times the risk of bladder cancer as women.

Age

Bladder cancer risk increases with age. About 9 in 10 people diagnosed with it are older than 55. It’s rare under age 40.

Arsenic in drinking water

The likelihood of having arsenic in drinking water depends on the source of the water. Most public water systems have standards for low arsenic content.

Personal history of bladder cancer

Bladder cancer has the highest recurrence rate of any cancer. About 50% to 80% of bladder cancers return after treatment.

Prior chemotherapy or radiation therapy

Previous treatment with the chemotherapy drug cyclophosphamide (Cytoxan), or previous radiation treatment to the pelvic area, can raise bladder cancer risk.

Family history

People who have family members with bladder cancer have an increased risk of the disease, possibly due to shared exposure to tobacco smoke or cancer-causing chemicals.

Inherited genetic syndromes

In rare cases, inherited mutations in certain genes may increase the risk of bladder cancer, including the retinoblastoma (RBI) gene, Cowden disease and Lynch syndrome.

Having any of these risk factors does not mean you will develop bladder cancer. But if you’re concerned about your risk, especially if you have a family history of bladder cancer or inherited gene mutations, talk with your doctor.

There are no screening exams to detect the disease in people with an average risk. If you have a high risk of bladder cancer, your doctor may want to test for it, even if you have no symptoms.

Bladder cancer cannot be completely prevented, but taking steps to reduce the risk factors that are within your control may help with bladder cancer prevention.

Preventive factors

The following protective factors may help prevent bladder cancer:

• Avoid tobacco
• Limit exposure to workplace chemicals known to cause cancer
• Drink plenty of water

Bladder cancer can often be detected early. One of the first signs is blood in the urine. Early symptoms of bladder cancer include:

• Blood in the urine that may come and go
• Urinating more often than usual
• Pain or burning sensation while urinating
• Feeling as if you need to go right away, even when the bladder is not full (urgency)
• Having difficulty urinating or having a weak urine stream

Keep in mind that many of these symptoms are very likely to be caused by non-cancerous conditions, such as a urinary tract infection (UTI), overactive bladder or an enlarged prostate. But let your doctor know if you’re experiencing anything unusual, so that you can find and treat any potential problems.

As bladder cancer advances, symptoms may include:

• Being unable to urinate
• Lower back pain on one side
• Loss of appetite
• Unintended weight loss
• Swelling in the feet

If you have any of these symptoms, call your doctor to determine the cause and next steps.

If you have bladder cancer symptoms or you have a very high risk of bladder cancer, your doctor may recommend testing. Scripps Cancer Center physicians use advanced imaging and lab tests to diagnose bladder cancer. These may include:

Urinalysis

The simple urine test can detect blood and other substances in the urine. Blood in the urine is usually the first symptom of bladder cancer, but it can be caused by other non-cancerous conditions.

Urine cytology

This test examines a urine sample for signs of abnormal cells that may indicate cancer. Cytology alone cannot confirm a cancer diagnosis.

Urine cystoscopy

A urine cystoscopy is the most common test to check for bladder cancer. The physician inserts a thin tube with a camera on the end (cystoscope) through the urethra and into the bladder to examine the walls of the bladder for abnormal growths. Cystoscopy also may be used to remove a tissue sample from the bladder for a biopsy and to remove early stage tumors on the surface of the bladder wall.

Intravenous pyelogram (IVP)

During IVP, the physician injects an iodine-based dye into a vein, and then takes a series of X-ray images to look for any abnormal growths.

Biopsy

During a biopsy, the doctor removes a small tissue sample from the bladder to be examined under a microscope.

Computed tomography (CT) scan

A CT scan is an imaging test that captures images of the body from different angles. The images are combined to create detailed cross-sectional views of organs, bones and blood vessels.

Magnetic resonance imaging (MRI)

MRI relies on a powerful magnet, radio waves and advanced digital technology to provide detailed images of organs, bone and soft tissue.

Positron emission tomography (PET) scan

A PET scan involves a type of radioactive sugar that existing cancer cells will quickly absorb so they can be identified under a special camera. It’s combined with a CT scan to give physicians the ability to view a picture of potentially cancerous areas through the PET while also seeing more detailed images from a CT scan.

Bladder cancer stages describe how far cancer has (or has not) spread beyond its original starting point in the bladder. Staging guides Scripps oncologists in developing a bladder cancer prognosis and treatment plan.

Stage 0

Abnormal cells are found in tissue lining the inside of the bladder. These abnormal cells may become cancer and spread to other areas. Stage 0 bladder cancer has two substages:

• Stage 0a (also called papillary carcinoma) may look like tiny mushrooms growing on the lining of the bladder.
• Stage 0is (also called carcinoma in situ) is a flat tumor on the lining of the bladder.

Stage I

Stage I bladder cancer has spread to the layer of tissue under the inner lining of the bladder.

Stage II

Stage II bladder cancer has spread to the muscle wall of the bladder.

Stage III

Stage III bladder cancer has spread from the bladder to the layer of tissue surrounding it, and may have spread to the reproductive organs.

Stage IV

Stage IV bladder cancer has spread from the bladder to the wall of the abdomen or pelvis, and may have spread to one or more lymph nodes or to other parts of the body.

A bladder cancer diagnosis can turn your world upside down. It’s completely normal to feel anxious, scared, depressed or overwhelmed. Learning all you can about your diagnosis and your options can help you make informed, confident decisions about the next steps to take.

Questions and considerations

Here are some questions you may want to ask your doctor or health insurance provider regarding your diagnosis:

• Should I get a second opinion?
• How do I find a specialist?
• What is my cancer treatment plan?
• Will I have to miss work/school?
• What are the side effects of bladder cancer treatment?
• How successful is my treatment likely to be?
• What costs will be covered by insurance?
• Which costs will I be responsible for?

Your Scripps team is here to help you find the answers you need to take an active role in your care. In addition, there are a number of community cancer resources that provide education, information and helpful resources — often at no cost.

Learn more about the many cancer patient resources available to you and your loved ones via Scripps.

Your cancer care team includes professionals from every area of oncology, including urologists, surgeons, radiation oncologists, medical oncologists and nurses who specialize in cancer care. Should you need reconstructive surgery after your bladder cancer treatment, count on our surgeons for the expertise that has brought comfort and confidence to many patients.

In addition, your nurse navigator will help coordinate your care and ensure you have support and guidance throughout your treatment and recovery. Learn more about how Scripps puts you at the center of care.

Your Scripps cancer care team will customize your treatment plan based on several factors, including:

• The stage of your cancer
• Whether your cancer has spread
• Your age and overall health

Treatment for bladder cancer typically involves surgery. Other treatments, such as radiation and chemotherapy, may be given before or after surgery.

Bladder cancer surgery

Depending on the bladder cancer stage, surgery may be the first treatment option. Surgical treatments for bladder cancer include:

• Transurethral resection (TUR) is the most common treatment for early stage bladder cancer. It removes tumors from the surface of the bladder wall using a resectoscope, which is a thin instrument with a wire loop on the end. The resectoscope is inserted into the bladder through the urethra. After the tumor is removed, remaining cancer cells may be destroyed with high-energy electricity or a laser.
• Cystectomy is used for more advanced bladder cancers. It involves the removal of part or all of the bladder. Depending on how far the cancer has spread, lymph nodes near the bladder also may be removed, as well as the prostate in men, and the uterus, ovaries and fallopian tubes in women. This procedure can also be performed with robot-assisted surgery though the Scripps Minimally Invasive Robotic Surgery Program.
• Bladder reconstruction surgery is an option when bladder cancer requires surgical removal of the bladder. It involves surgical procedures known as urinary diversions, which allow the body to store and eliminate urine through a different path, such as through the colon or through an opening in the abdomen into an external bag.

Radiation therapy

Radiation therapy may be part of a bladder cancer treatment plan before surgery to shrink the tumor, or after surgery to eliminate remaining cancer cells. Scripps provides the most advanced radiation treatments for bladder cancer, including:

• Intensity-modulated radiation therapy (IMRT) is an advanced form of radiation therapy. IMRT allows the radiation oncologist to specify the dose of radiation for the tumor while restricting the dose to surrounding healthy tissues.
• 3-D conformal radiation therapy allows the radiation oncologist to visualize a patient’s anatomy in 3-D. It uses specialized software to match radiation doses to the size and shape of a tumor while minimizing exposure to nearby healthy tissues and organs.

Chemotherapy

The treatment plan may include chemotherapy if bladder cancer has spread to the lymph nodes and other parts of the body. It may be used in combination with surgery and radiation therapy.

Immunotherapy

Also called biologic therapy, immunotherapy is designed to use the body’s own immune system to fight cancer. In the case of bladder cancer, the bacterial organism bacillus Calmette-Guérin (BCG) may be administered directly into the bladder through a catheter. BCG is the most effective biologic treatment to prevent bladder cancer from returning.

Some cancer treatment plans may involve clinical trials. Talk with your physician about whether a bladder cancer clinical trial is right for you.

For a list of clinical trial that are currently enrolling patients, see our current list of clinical trials.

Your Scripps cancer team will develop a customized treatment plan outlining the treatments and therapies we recommend for your care. Before you begin treatment, you and your physician will review your plan together and discuss any questions or concerns you may have.

Your bladder cancer treatment plan generally includes:

• Family and medical history
• A summary of your cancer diagnosis and staging information
• Diagnostic testing completed (e.g., imaging, biopsy, lab tests)
• Plans for surgery, radiation, chemotherapy and/or other treatments
• Potential side effects of treatments
• Contact information for your cancer care team members

Along with helping you understand your course of treatment and encouraging discussion between you and your physician, your plan helps your team coordinate your care. You also can share your treatment plan with other providers who may be involved in your medical care.

Your bladder cancer care team includes health and medical professionals from a wide range of specialties. Scripps will customize your team to ensure you have the expertise and support you need.

Your team may include:

• Urologists
• Surgeons and surgical oncologists
• Radiation oncologists
• Medical oncologists
• Registered nurses
• Nurse navigators
• Dietitians
• Oncology social workers

Visit your cancer care team for more on Scripps Cancer Center's multidisciplinary approach to treatment.

In addition to the bladder cancer support group listed below, we also host a handful of free workshops and health and wellness events on a number of topics such as:

• Nutrition
• Expressive writing
• Yoga
• Meditation

For info about other cancer support groups in the San Diego community, call the American Cancer Society at 800-227-2345.