Bladder Cancer: Complete Guide
Quick Facts
- 6th most common cancer in the United States
- 4 times more common in men than women
- Average age at diagnosis: 73 years
- Smoking is the #1 risk factor (50% of cases)
- Blood in urine is most common symptom
- 75% diagnosed at early, non-invasive stage
- 5-year survival rate: 77% overall, 96% for localized
- High recurrence rate requiring lifelong surveillance
What is Bladder Cancer?
Bladder cancer begins when cells in the urinary bladder start to grow uncontrollably. The bladder is a hollow organ in the lower pelvis that stores urine before it leaves the body. Most bladder cancers start in the innermost lining of the bladder (urothelium).
Key Points
- Most bladder cancers (70-80%) are non-muscle-invasive at diagnosis
- Highly treatable when caught early
- Requires lifelong monitoring due to high recurrence rate
- Smoking cessation significantly reduces risk
- New immunotherapies improving outcomes
Bladder Anatomy
- Urothelium (transitional epithelium): Inner lining where most cancers start
- Lamina propria: Connective tissue layer
- Muscularis propria: Thick muscle layer
- Perivesical fat: Fatty tissue surrounding bladder
Types of Bladder Cancer
By Cell Type
- Urothelial Carcinoma (90%):
- Also called transitional cell carcinoma
- Begins in urothelial cells lining bladder
- Most common type
- Squamous Cell Carcinoma (3-5%):
- Associated with chronic irritation/infection
- More common in areas with schistosomiasis
- Often more aggressive
- Adenocarcinoma (1-2%):
- Develops from glandular cells
- Can be primary or from nearby organs
- Small Cell Carcinoma (<1%):
- Neuroendocrine tumor
- Highly aggressive
- Treated similar to small cell lung cancer
By Invasion Depth
- Non-Muscle-Invasive Bladder Cancer (NMIBC) - 75%:
- Limited to urothelium or lamina propria
- Stages Ta, Tis (CIS), T1
- Better prognosis
- High recurrence rate (50-70%)
- Muscle-Invasive Bladder Cancer (MIBC) - 25%:
- Invades muscle layer or beyond
- Stages T2-T4
- Higher risk of metastasis
- Often requires cystectomy
Special Subtypes
- Carcinoma in situ (CIS): Flat, high-grade cancer confined to urothelium
- Papillary urothelial carcinoma: Finger-like projections, better prognosis
- Variant histologies: Micropapillary, plasmacytoid, sarcomatoid (worse prognosis)
Signs and Symptoms
Early Symptoms
- Hematuria (blood in urine) - 80-90% of patients:
- Gross hematuria: Visible blood (pink, red, or cola-colored urine)
- Microscopic hematuria: Only detected by testing
- May be painless
- May come and go
- Changes in urination:
- Increased frequency
- Urgency
- Painful urination (dysuria)
- Difficulty urinating
Advanced Symptoms
- Lower back pain (one-sided)
- Inability to urinate
- Pelvic pain
- Bone pain (if metastatic)
- Weight loss and fatigue
- Swelling in feet (lymphatic obstruction)
⚠️ Important Note About Blood in Urine
Any blood in the urine should be evaluated by a healthcare provider, even if:
- It happens only once
- It's painless
- The amount is small
- It goes away on its own
While most hematuria is NOT cancer, it requires investigation to rule out serious causes.
Causes and Risk Factors
Primary Risk Factors
- Smoking:
- Accounts for 50% of bladder cancers
- Smokers 3x risk of non-smokers
- Risk decreases after quitting but remains elevated
- All tobacco products increase risk
- Occupational exposures:
- Aromatic amines (dye industry)
- Rubber, leather, textile workers
- Painters, hairdressers
- Truck drivers (diesel exhaust)
- Aluminum workers
- Chemical exposures:
- Arsenic in drinking water
- Chlorination byproducts
- Benzene and other solvents
Other Risk Factors
- Age: Risk increases significantly after age 55
- Gender: Men 3-4x more likely than women
- Race: Whites 2x risk of African Americans
- Previous bladder cancer: High recurrence rate
- Chronic bladder inflammation:
- Recurrent UTIs
- Bladder stones
- Long-term catheter use
- Schistosomiasis (parasitic infection)
- Chemotherapy: Prior cyclophosphamide or ifosfamide
- Radiation: Pelvic radiation for other cancers
- Family history: 2x risk with affected relative
- Genetic conditions: Lynch syndrome, others
Diagnosis
Initial Evaluation
- Complete medical history (smoking, occupational exposures)
- Physical examination (including pelvic/rectal exam)
- Urinalysis and urine culture
Cystoscopy
Gold standard for bladder cancer diagnosis:
- Direct visualization of bladder interior
- Flexible or rigid scope through urethra
- Can identify tumors, location, number
- Usually office procedure with local anesthesia
- Biopsy can be performed
Urine Tests
- Urine cytology: Examines cells shed in urine (better for high-grade)
- Urine markers:
- UroVysion FISH
- NMP22
- BTA stat
Imaging Studies
- CT urography: Evaluates upper urinary tract
- MRI: Better soft tissue detail for staging
- Chest X-ray or CT: Check for lung metastases
- Bone scan/PET: If symptoms suggest metastases
Transurethral Resection (TURBT)
- Diagnostic AND therapeutic procedure
- Removes visible tumors
- Provides tissue for staging
- Must include muscle in sample for proper staging
- Repeat TURBT often needed for high-grade T1
Staging
TNM Staging System
| Stage | T Stage | Description | 5-Year Survival |
|---|---|---|---|
| Stage 0a | Ta | Non-invasive papillary carcinoma | 98% |
| Stage 0is | Tis (CIS) | Carcinoma in situ (flat tumor) | 96% |
| Stage I | T1 | Invades connective tissue below lining | 88% |
| Stage II | T2a/T2b | Invades muscle layer | 63% |
| Stage IIIA | T3a/T3b/T4a | Invades fatty tissue or nearby organs | 46% |
| Stage IIIB | Any T, N1-3 | Spread to lymph nodes | 35% |
| Stage IV | Any T, any N, M1 | Distant metastases | 5% |
Grading
- Low-grade: Slow-growing, less aggressive, better prognosis
- High-grade: Fast-growing, more aggressive, worse prognosis
Treatment Options
Non-Muscle-Invasive Bladder Cancer (Ta, Tis, T1)
Initial Treatment
- TURBT: Transurethral resection removes tumor
- Single-dose chemotherapy: Immediately after TURBT (mitomycin or gemcitabine)
Additional Treatment Based on Risk
- Low-risk:
- TURBT alone may be sufficient
- Surveillance with cystoscopy
- Intermediate-risk:
- Intravesical chemotherapy (6 weekly doses)
- Or BCG immunotherapy
- High-risk (including CIS):
- BCG immunotherapy (induction + maintenance)
- If BCG fails: cystectomy or other options
Muscle-Invasive Bladder Cancer (T2-T4)
Curative Intent
- Radical cystectomy (preferred):
- Men: Removal of bladder, prostate, seminal vesicles
- Women: Removal of bladder, uterus, ovaries, part of vagina
- Pelvic lymph node dissection
- Urinary diversion required
- Neoadjuvant chemotherapy: Before surgery (recommended)
Bladder-Sparing Approaches
- Trimodality therapy:
- Maximal TURBT + chemotherapy + radiation
- For selected patients
- Preserves bladder function
Urinary Diversion Options After Cystectomy
- Ileal conduit: Urine drains to external bag (most common)
- Continent cutaneous reservoir: Internal pouch, catheterized through stoma
- Neobladder: Bladder reconstruction from intestine (preserves normal urination)
Metastatic Disease
- First-line chemotherapy:
- Cisplatin-based: MVAC or GC (gemcitabine-cisplatin)
- Carboplatin-based if cisplatin-ineligible
- Immunotherapy:
- Pembrolizumab (Keytruda)
- Atezolizumab (Tecentriq)
- Nivolumab (Opdivo)
- Avelumab (Bavencio) - maintenance
- Targeted therapy:
- Enfortumab vedotin (antibody-drug conjugate)
- Erdafitinib (FGFR inhibitor)
BCG Immunotherapy
💉 About BCG Therapy
Bacillus Calmette-Guérin (BCG) is a weakened strain of tuberculosis bacteria used to treat high-risk non-muscle-invasive bladder cancer. It's instilled directly into the bladder.
How BCG Works
- Stimulates local immune response
- Immune cells attack cancer cells
- Most effective intravesical therapy for high-risk disease
- Reduces recurrence and progression
BCG Schedule
- Induction: Weekly for 6 weeks
- Maintenance:
- 3 weekly doses at 3, 6, 12, 18, 24, 30, 36 months
- Duration: 1-3 years
- Improves efficacy compared to induction alone
BCG Administration
- Catheter inserted into bladder
- BCG solution instilled
- Hold in bladder for 2 hours (change position every 15 min)
- Void sitting down (reduce splash)
- Avoid intercourse for 48 hours
BCG Side Effects
- Common (local):
- Urinary frequency/urgency
- Dysuria (burning)
- Blood in urine
- Flu-like symptoms
- Low-grade fever
- Serious (rare):
- BCG sepsis (high fever >103°F, seek immediate care)
- Systemic infection
- Contracted bladder
BCG-Unresponsive Disease
If cancer persists or recurs after adequate BCG:
- Radical cystectomy (standard)
- Clinical trial
- Alternative intravesical therapy
- Pembrolizumab (for CIS)
Prognosis and Survival Rates
Overall Survival
- 5-year relative survival: 77%
- 10-year relative survival: 70%
By Stage at Diagnosis
- Localized (in bladder only): 96% 5-year survival
- Regional (spread to nearby structures/nodes): 70% 5-year survival
- Distant (metastatic): 8% 5-year survival
Factors Affecting Prognosis
Favorable
- Low-grade, low-stage disease
- Single small tumor
- No CIS
- Complete TURBT
- Good response to BCG
Unfavorable
- High-grade, high-stage
- CIS present
- Variant histologies
- Lymphovascular invasion
- Positive lymph nodes
- Incomplete resection
Follow-up and Surveillance
Why Surveillance is Critical
- 50-70% recurrence rate for NMIBC
- 10-30% progression to muscle-invasive
- Early detection of recurrence improves outcomes
- Lifelong monitoring required
Surveillance Schedule (NMIBC)
Low-Risk
- Cystoscopy at 3 months
- If negative: annually for 5 years
Intermediate-Risk
- Cystoscopy every 3-6 months for 2 years
- Then every 6-12 months for years 3-5
- Then annually
High-Risk
- Cystoscopy every 3 months for 2 years
- Then every 6 months for years 3-5
- Then annually lifelong
- Upper tract imaging periodically
After Cystectomy
- CT chest/abdomen/pelvis every 6 months × 2 years
- Then annually for 5 years
- Urethral wash cytology if at risk
- Upper tract imaging annually
Prevention Strategies
Primary Prevention
- Don't smoke or quit smoking:
- Most important prevention strategy
- Risk decreases after quitting
- Never too late to quit
- Workplace safety:
- Follow safety procedures with chemicals
- Use protective equipment
- Good ventilation
- Hydration: Drink plenty of fluids (dilutes urine, frequent voiding)
- Varied diet: Fruits and vegetables may be protective
Secondary Prevention (After Diagnosis)
- Strict adherence to surveillance schedule
- Complete BCG course as prescribed
- Quit smoking (improves outcomes)
- Report symptoms promptly
Frequently Asked Questions
Is blood in urine always cancer?
No. Most hematuria is NOT cancer. Common causes include UTIs, kidney stones, enlarged prostate, vigorous exercise, and medications. However, any blood in urine requires medical evaluation to rule out serious causes.
How is bladder cancer different from other cancers?
Bladder cancer has a very high recurrence rate (50-70%) even after successful treatment, requiring lifelong surveillance. Many cases are caught early and treated without removing the bladder.
Will I need a urostomy bag?
Most patients with non-muscle-invasive bladder cancer keep their bladder. Only muscle-invasive disease typically requires cystectomy with urinary diversion. Some diversion options (neobladder) don't require an external bag.
What is BCG and why is it used?
BCG is a weakened tuberculosis bacteria that stimulates the immune system to attack cancer cells when instilled in the bladder. It's the most effective treatment for high-risk non-muscle-invasive bladder cancer.
Can I prevent bladder cancer from coming back?
While you can't guarantee prevention, you can reduce risk by: quitting smoking, completing all prescribed BCG treatments, following surveillance schedule, and maintaining good overall health.
How often will I need cystoscopy?
Frequency depends on your risk level. Low-risk may need annual cystoscopy after initial surveillance. High-risk requires cystoscopy every 3 months initially, then every 6 months, then annually - often lifelong.
Is bladder cancer hereditary?
Most bladder cancer is not hereditary. However, having a family history doubles your risk, and some hereditary syndromes (Lynch syndrome) increase risk. Genetic counseling may be appropriate for families with multiple cases.
What happens if BCG doesn't work?
If cancer persists or recurs after adequate BCG therapy, options include: radical cystectomy (standard recommendation), clinical trials, alternative intravesical therapies, or immunotherapy (pembrolizumab for CIS).
Related Topics
Medical Disclaimer
This information is for educational purposes only and should not replace professional medical advice. Always consult with qualified healthcare providers for diagnosis and treatment decisions. Bladder cancer treatment requires individualized care based on specific tumor characteristics and patient factors.
Sources
- National Cancer Institute. Bladder Cancer Treatment (PDQ) - Health Professional Version. Updated January 2026.
- American Cancer Society. Bladder Cancer Statistics. 2026.
- NCCN Clinical Practice Guidelines. Bladder Cancer. Version 1.2026.
- Chang SS, et al. AUA/SUO Guideline: Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer. 2025.
- Flaig TW, et al. Bladder Cancer, Version 3.2025, NCCN Clinical Practice Guidelines in Oncology.
- EAU Guidelines on Non-Muscle-Invasive Bladder Cancer. 2025.