Bladder Cancer

Bladder cancer occurs when cells in the bladder start to grow without control, forming tumors in the organ that stores urine. While it’s the sixth most common cancer in the United States and fourth most common in men, most cases are caught early and are treatable, though the disease often comes back after treatment.

What is bladder cancer
The bladder and urinary system
Types of bladder cancer
Who gets bladder cancer
Symptoms and warning signs
How bladder cancer is diagnosed
Treatment options
Understanding cancer recurrence
Living with and after bladder cancer

What is bladder cancer

Bladder cancer is a relatively rare form of cancer that starts in the lining of your bladder. The bladder is a small, hollow, balloon-shaped organ in the lower part of the abdomen that stores urine.^[1]^[2]

Bladder cancer happens when certain cells in the tissue lining your bladder mutate or change, becoming abnormal cells that multiply and cause tumors. Left untreated, bladder cancer may grow through your bladder walls to nearby lymph nodes and then other areas of your body, including your bones, lungs or liver.^[3]

Healthcare providers can treat early-stage bladder cancer—cancer that’s found and treated before it can spread—but about 75% of early-stage bladder cancers come back.^[3] This makes regular follow-up care extremely important for anyone who has been diagnosed with this disease.

Bladder
Urethra
Ureters
Kidneys
Renal pelvis

The bladder and urinary system

Your bladder is a triangle-shaped organ centered between your hip bones, above your urethra and below your kidneys. The bladder has a muscular wall that allows it to get larger to store urine made by the kidneys and to shrink to squeeze urine out of the body.^[2]^[3]

The bladder and kidneys work together to remove toxins and wastes from your body through urine. Here’s how the system works: Tiny tubules in the kidneys filter and clean the blood, taking out waste products and making urine. The urine passes from each kidney through a long tube called a ureter (a tube that carries urine from the kidney to the bladder) into the bladder. The bladder holds the urine until it passes through a tube called the urethra (the tube that carries urine out of the body) and leaves the body.^[2]

The bladder is lined with tissue called urothelium, which is made of cells that stretch when your bladder fills with urine and collapse when it’s empty. Your bladder can hold about 2 cups of urine.^[3]

Types of bladder cancer

There are several types of bladder cancer. Each type is named for the cells that line the wall of your bladder where the cancer started.^[3]

Urothelial carcinoma (also called transitional cell carcinoma) is cancer that begins in the urothelial cells, which line the urethra, bladder, ureters, renal pelvis, and some other organs. Almost all bladder cancers—about 90% of cases in industrialized nations—are urothelial carcinomas.^[2]^[4] Urothelial cells are also called transitional cells because they change shape. These cells are able to stretch when the bladder is full of urine and shrink when it is emptied.

In this cancer type, abnormal cells may spread from the inner lining to other layers deep in your bladder or through your bladder wall into fatty tissues that surround your bladder.^[3]

Other, less common types of bladder cancer include:

Squamous cell carcinoma: This cancer begins in squamous cells, which are thin, flat cells that line the inside of your bladder. This type accounts for about 5% of bladder cancers and typically develops in people who’ve had long bouts of bladder inflammation or irritation. This type of cancer may form after long-term irritation or infection with a tropical parasite called schistosomiasis, which is common in Africa and the Middle East but rare in the United States.^[2]^[3]
Adenocarcinoma: This is cancer that begins in glandular cells that are found in the lining of the bladder. Glandular cells in the bladder make mucus and other substances. This is a very rare type of bladder cancer, accounting for 1% to 2% of all bladder cancers.^[2]^[3]
Small cell carcinoma of the bladder: This is cancer that begins in neuroendocrine cells (nerve-like cells that release hormones into the blood in response to a signal from the nervous system). This extremely rare type of bladder cancer affects about 1,000 people in the U.S.^[2]^[3]
Sarcoma: Rarely, soft tissue sarcomas start in bladder muscle cells.^[3]

Healthcare providers may also categorize bladder cancer by how deeply it has grown into the bladder wall:^[2]^[3]

Noninvasive: This bladder cancer may be tumors in a small section of tissue or cancer that’s only on or near the surface of your bladder.
Non-muscle-invasive: This refers to bladder cancer that’s moved deeper into your bladder but hasn’t spread to muscle. Most bladder cancers are non-muscle-invasive.
Muscle-invasive: This bladder cancer has grown into bladder wall muscle and may have spread into the fatty layers or tissues on organs outside of your bladder.

Who gets bladder cancer

Bladder cancer is the fourth most common cancer in males. Men are four times more likely to develop bladder cancer than women. However, women who do have bladder cancer typically have advanced forms of the disease because they don’t know about bladder cancer symptoms.^[3]

This type of cancer is notably common among older adults. People over the age of 55 are more at risk.^[1] Each year in the U.S., there are almost 80,000 new cases. In 2023, there were an estimated 82,000 new cases diagnosed and approximately 17,000 deaths in the U.S. alone.^[13]

Several risk factors increase the chances of developing bladder cancer:^[1]

Smoking: As the bladder works to filter the harmful chemicals ingested in cigarette smoke, it becomes damaged. In fact, smokers are three times more likely to get bladder cancer. Smoking is thought to be the cause of about half of all bladder cancers.^[1]^[5]
Age: People over 55 are at higher risk.
Gender: Men are more likely than women to develop the disease.
Exposure to harmful chemicals: Either at home or at work.
Previous cancer treatments: Such as radiation therapy.
Chronic bladder inflammation: Long-term irritation of the bladder.
Family history: Having relatives who had bladder cancer can play a role.

Symptoms and warning signs

Bladder cancer symptoms are usually clear and easy to notice.^[1] If any of these symptoms are present, it may be worth making an appointment to see a doctor:

Blood in the urine (gross or microscopic hematuria, meaning blood in the urine that can be seen or detected only under a microscope)
Frequent urination
Painful urination
Back pain
Unexplained pelvic pain

Some of the early signs of bladder cancer can be easy to dismiss. Lower back pain and painful or frequent urination can point to any number of benign conditions, including urinary tract infection and kidney stones. It’s the unsettling discovery of blood in the urine that sends most people with bladder cancer in search of medical advice.^[5]

Many bladder cancer symptoms are also seen with other less serious conditions. However, these are warning signs you shouldn’t ignore. Your doctor may investigate the more common causes of the symptoms first, or may refer you to a specialist, like a urologist or an oncologist.^[1]

How bladder cancer is diagnosed

Presenting symptoms such as gross or microscopic hematuria, urinary frequency, and unexplained pelvic pain typically lead to its detection.^[4] The most common clinical presentation is asymptomatic hematuria, which should prompt evaluation with cystoscopy (a procedure where a tube is inserted to view inside the bladder), renal function testing, and upper urinary tract imaging in adults 35 years and older and in those with irritative voiding symptoms, risk factors for bladder cancer, or gross hematuria at any age.^[12]

Transurethral resection of the bladder tumor (a surgical procedure to remove tumors) allows for definitive diagnosis, staging, and primary treatment. This procedure is often the first step in both diagnosing and treating bladder cancer.^[4]^[12]

Various imaging tests may be used to help diagnose and stage bladder cancer, including ultrasound, CT scans, and MRI scans.

Treatment options

Healthcare providers have many ways to treat bladder cancer. Different types of treatment are available, and you and your cancer care team will work together to decide your treatment plan, which may include more than one type of treatment.^[10]

Many factors will be considered, such as the stage and grade of the cancer, your overall health, and your preferences. The treatment options depend on the grade and stage of your tumor.^[8]

For non-muscle-invasive bladder cancer

Non-muscle-invasive disease is treated with transurethral resection, most often followed by intravesical (directly into the bladder) therapy.^[12] After the doctor removes all the cancer that can be seen during surgery, some patients may be given additional treatment to kill any cancer cells that are left.^[10]

Bacillus Calmette-Guérin (BCG) was the first FDA-approved immunotherapy and helps reduce the risk of bladder cancer recurrence by stimulating an immune response that targets the bacteria as well as any nearby bladder cancer cells. BCG uses weakened bacteria to stimulate the immune system and is approved for early-stage bladder cancer. Approximately 70% of bladder cancer patients go into remission after BCG therapy.^[13]

Intravesical chemotherapy may also be used. Treatment is typically with transurethral resection, most often followed by one dose of chemotherapy, usually mitomycin C, within the bladder.^[5]

For muscle-invasive bladder cancer

Bladder cancer that invades the muscle layer is typically treated with radical cystectomy (surgical removal of the bladder) and neoadjuvant chemotherapy (chemotherapy given before surgery).^[12] Standard treatment for patients with bladder cancer that has invaded muscle tissue includes cisplatin-based chemotherapy followed by surgical removal of the bladder or radiation therapy and concomitant chemotherapy.^[5]

Radical cystectomy with urinary diversion is surgery to remove the bladder and any lymph nodes and nearby organs that contain cancer. This surgery may be done when the bladder cancer invades the muscle layers or when non-muscle-invasive bladder cancer involves a large part of the bladder. In men, the nearby organs that are removed are the prostate and the seminal vesicles. In women, the uterus, the ovaries, and part of the vagina are removed.^[10]

When the bladder must be removed, the surgeon performs a procedure called urinary diversion to create another way for the body to store and pass urine. It may involve redirecting urine into the colon, using catheters to drain the bladder, or making an opening in the abdomen that connects to a bag outside the body for collecting urine.^[10]

Other treatment approaches

Treatment primarily involves transurethral resection and intravesical chemotherapy instillations but may also include laser ablation, radiation therapy, chemotherapy, or surgical removal of part or all of the bladder.^[4]

Radiation therapy uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. Bladder cancer is sometimes treated with external beam radiation therapy, which uses a machine outside the body to send radiation toward the area of the body with cancer.^[10]

Several types of immunotherapy drugs are now approved for certain patients with bladder cancer, including targeted antibodies and immunomodulators that help the immune system fight cancer.^[13]

Recent advances in treatment

A new drug-releasing system, TAR-200, eliminated tumors in 82% of patients in a phase 2 clinical trial for individuals with high-risk non-muscle-invasive bladder cancer whose cancer had previously resisted treatment. TAR-200 is a miniature, pretzel-shaped drug-device duo containing a chemotherapy drug, gemcitabine, which is inserted into the bladder through a catheter and releases the drug for three weeks per treatment cycle. In the majority of cases, the cancer disappeared after only three months of treatment, and almost half the patients were cancer-free a year later.^[9]

Understanding cancer recurrence

It’s common for bladder cancer to come back, even after successful treatment. As a result, it is important for people who have been treated for bladder cancer to visit their doctor regularly to get certain follow-up exams or tests.^[17]

Evidence suggests non-muscle invasive bladder cancers (making up approximately 70% of those diagnosed with urothelial carcinoma) have a high recurrence rate—up to 70% within two years of treatment.^[15] Because their disease is likely to recur, or come back, patients with bladder cancer must undergo surveillance for an extended period.^[3]

When considered by stage, the 5-year relative survival rates vary significantly. For patients with tumors restricted to the inner layer of the bladder or those with disease localized to the bladder, the rates are 96% and 70%, respectively. The rates drop to 34% for those with disease that has spread locally beyond the bladder and to 5% for patients with distant metastases.^[13]

Living with and after bladder cancer

Completing your treatment and pushing bladder cancer back into remission is a reason to celebrate. However, as many survivors know, cancer does not end after treatment. Managing life after bladder cancer isn’t easy, but it’s possible.^[15]

Coping with emotions

You may have several different feelings when you are told you have cancer. You may feel shocked, upset, numb, frightened and uncertain, confused, angry and resentful, or guilty. You may feel some or all of these feelings, or you may feel totally different. Everyone reacts in their own way.^[18]

Fear that the cancer will come back is one of the most common concerns experienced by survivors. In this respect, time heals, and many cancer survivors report thinking about the disease less often as the years go by.^[15]

It’s normal to have concerns and ask questions: What steps can I take to prevent recurrence? How do I cope with the fear of it returning? How do I stay positive and keep my energy levels up?^[15]

Talking to your friends and relatives about your cancer can help and support you. You might find it easier to talk to someone other than your own friends and family. For support and information, you can call support services or speak with a counselor.^[18]

Physical adjustments

For those who have a stoma and urostomy bag (following bladder removal surgery), getting used to them takes time. Some people need to learn how to use a catheter to empty their bladder, which is another big change. And if you have incontinence or problems controlling your bladder, it can be frustrating to deal with. Know that you aren’t alone in how you feel. Adjusting to these changes can be hard. But, over time, many people are able to do a lot of what they did before surgery.^[17]

Body changes may affect your self-image and sex life after treatment. Some treatments for bladder cancer, including chemotherapy, radiation therapy, surgery, or certain medicines, can cause short-term or long-term problems with sex.^[17]

Steps to protect your bladder

After bladder cancer treatment, you can take steps to help protect your bladder from recurrence:^[15]

Quit smoking: Smoking is thought to be the cause of about half of all bladder cancers. Although quitting can be tough, it’ll help you feel healthier overall and less anxious about cancer.
Stay hydrated: Drinking lots of fluids, particularly water, may lower your risk of developing bladder cancer. Try to drink six to eight glasses of water a day.
Get your fruits and veggies: A diet high in fruits and vegetables may help keep your bladder healthy. Aim to have at least five servings of fruits and vegetables every day, and also eat whole grains several times a day.
Exercise: Regular exercise helps reduce the risk of recurrence and can add more years to your life. Only 30 minutes a day of moderate exercise reduces anxiety and symptoms such as fatigue, nausea and pain.

Follow-up care

Planning and scheduling follow-up appointments can be stressful and time-consuming. Waiting for test results can cause anxiety and an ongoing fear of recurrence. The added costs of things such as copays, medicines, and parking and transportation fees only add to the stress.^[17]

Make sure you know who your specialist nurse is and have their telephone number. Specialist nurses can help if you’re finding it difficult to cope or if you have any problems. They can get you the help you need. They can also give you information and signpost you to support in your local area.^[18]