Bladder Cancer Stage I with Carcinoma in Situ

Stage I bladder cancer with carcinoma in situ is an early but aggressive form of bladder cancer that requires careful treatment and monitoring, as it has a higher risk of returning or spreading compared to other early-stage cancers.

Table of contents

• What This Diagnosis Means
• Understanding Stage I and Carcinoma in Situ
• Common Symptoms
• Risk Factors and Recurrence
• Treatment Options
• Monitoring and Follow-Up

What This Diagnosis Means

When you are diagnosed with stage I bladder cancer with carcinoma in situ, you have two types of cancer present in your bladder at the same time. Stage I bladder cancer means the cancer has grown into the connective tissue (the layer beneath the inner lining) but has not reached the muscle layers of the bladder^[1][2]. This is also called a “superficial” bladder cancer, though it is more invasive than stage 0 disease^[2].

Carcinoma in situ (often shortened to CIS) is a flat type of cancer that spreads like a thin sheet along the surface of the bladder’s inner lining, called the urothelium^[3][4]. The term “in situ” means “in its original place,” so the cancer cells have not spread deeper into the bladder wall or to other parts of the body^[3]. However, CIS is always considered high-grade, meaning the cancer cells look very abnormal under the microscope and tend to be more aggressive^[3][4].

Understanding Stage I and Carcinoma in Situ

Stage I bladder cancer invades the subepithelial connective tissue, which is the layer just beneath the bladder’s inner lining, but it does not invade the muscle of the bladder and has not spread to lymph nodes^[2]. This stage is classified as non-muscle-invasive bladder cancer because it stays in the lining and connective tissue and has not reached the muscle layer^[3][4].

Carcinoma in situ makes up about 10 percent of non-muscle-invasive bladder cancer cases^[3][6]. Unlike other stage 0 cancers that may grow as finger-like projections, CIS is flat and does not form a visible lump. Instead, it spreads across the surface of the bladder lining^[3]. When CIS is present along with stage I disease, it is considered high-risk bladder cancer^[8][14].

Between 75 and 80 percent of all bladder cancers are non-muscle-invasive^[3]. At diagnosis, approximately 10 percent of patients with bladder cancer present with CIS^[6]. CIS is flat, high-grade, and aggressive, carrying a risk of progressing to more invasive disease^[6][10].

Common Symptoms

The most common symptom of bladder cancer is hematuria, which means blood in the urine^[3][5]. Depending on the amount of blood present, urine may appear pink, red, or brownish in color. Blood may not be present all the time—there may be periods of weeks or sometimes months when urine appears clear^[17].

Even though carcinoma in situ is an early-stage cancer, people with CIS commonly experience additional uncomfortable urinary symptoms. These symptoms depend on the size and location of the cancer and may include^[3][18]:

• Painful urination
• Frequent urination
• Feeling a sudden, urgent need to urinate
• Urge incontinence (urine leaking suddenly)

If you notice blood in your urine or experience any of these symptoms, it is important to speak to your doctor as soon as possible^[17].

Risk Factors and Recurrence

Management of carcinoma in situ of the bladder is complex and challenging because of its high rate of recurrence and progression^[6][10]. Although it is typically grouped with other non-muscle-invasive bladder cancers, its higher grade and aggressiveness make it a unique clinical condition^[6][10].

Historically, within 5 years of diagnosis, 40 to 60 percent of patients with CIS developed invasive disease, with an average risk of progression of 54 percent^[6][10]. However, after treatment with intravesical BCG therapy (a treatment placed directly into the bladder), a decrease in risk of progression to 9.8 percent has been reported in patients with CIS^[6][10].

Having carcinoma in situ in the bladder is associated with a less favorable outlook. It is more likely to come back after treatment, and there is a greater risk of CIS developing into invasive bladder cancer^[19]. Bladder cancer that comes back after treatment tends to have a poorer prognosis than bladder cancer that happens for the first time^[19].

Surgery alone is effective in preventing recurrences in approximately 50 percent of patients with superficial bladder cancer. Within 15 or 20 years, more than half of surviving patients will have experienced progressive cancer or will develop new cancers, including cancers of the upper urinary tract^[2].

Treatment Options

Standard initial treatment for all patients with stage I bladder cancer is a transurethral resection (TUR) with electrical or laser destruction of all visible cancer^[2][8][14]. A TUR is an operation performed for both the diagnosis and management of bladder cancer. During this procedure, a urologist inserts a thin, lighted tube called a cystoscope into the bladder through the urethra to examine the lining of the bladder. The urologist can remove samples of tissue through this tube or can remove some or all of the cancer in the bladder^[2].

Sometimes, surgery might be repeated if the first procedure does not remove enough of the tumor or does not include a sample from the muscle layer^[8][14]. If a repeat surgery finds that the cancer has invaded the muscle layer, it will be treated as muscle-invasive bladder cancer (stage II bladder cancer or higher)^[8][14].

Because stage I bladder cancer with carcinoma in situ is considered high-risk, treatment typically includes TUR followed by intravesical BCG therapy^[8][14]. Intravesical BCG is the standard first-line treatment given its superiority to other agents^[6][10]. Most people receive intravesical chemotherapy with mitomycin or gemcitabine or intravesical BCG at the time of their first surgery^[8][14].

To help lower the risk of bladder cancer recurrence, your doctor may recommend you continue having intravesical BCG for up to 3 years, depending on the characteristics of the cancer. This is called maintenance therapy^[8][14].

For patients with multiple tumors or carcinoma in situ, another option is surgery to remove part or all of the bladder^[8][14]. Radical cystectomy (complete removal of the bladder) has traditionally been the standard second-line treatment after BCG failure^[6][10]. Rarely, for more extensive or multiple superficial cancers, a segmental cystectomy (removal of part of the bladder) is necessary^[2].

Monitoring and Follow-Up

Surveillance with regular cystoscopies (bladder inspections with a camera) and possibly additional imaging tests are used to monitor for signs of cancer recurrence or progression^[8][14]. Because of the high rate of recurrence associated with carcinoma in situ, close monitoring is essential.

The presence of carcinoma in situ in the bladder increases the risk that cancer will come back after treatment^[19]. Non-invasive bladder cancer that comes back soon (a few months) after treatment tends to have a less favorable prognosis than a cancer that comes back long after treatment (many years later)^[19].

The prognosis for bladder cancer significantly improves the earlier it is discovered^[17]. Therefore, staying informed about your condition and following your doctor’s recommendations for monitoring is important for the best possible outcome.