Bladder Cancer | Vanderbilt-Ingram Cancer Center

Bladder Cancer Treatment

General Information About Bladder Cancer

Key Points

Bladder cancer is a disease in which malignant (cancer) cells form in the tissues of the bladder.
Smoking can affect the risk of bladder cancer.
Signs and symptoms of bladder cancer include blood in the urine and pain during urination.
Tests that examine the urine and bladder are used to diagnose bladder cancer.
Certain factors affect prognosis (chance of recovery) and treatment options.

Bladder cancer is a disease in which malignant (cancer) cells form in the tissues of the bladder.

The bladder is a hollow organ in the lower part of the abdomen. It is shaped like a small balloon and has a muscular wall that allows it to get larger or smaller to store urine made by the kidneys. There are two kidneys, one on each side of the backbone, above the waist. Tiny tubules in the kidneys filter and clean the blood. They take out waste products and make urine. The urine passes from each kidney through a long tube called a ureter into the bladder. The bladder holds the urine until it passes through the urethra and leaves the body.

Anatomy of the male urinary system (left panel) and female urinary system (right panel); two-panel drawing showing the right and left kidneys, the ureters, the bladder filled with urine, and the urethra. The inside of the left kidney shows the renal pelvis. An inset shows the renal tubules and urine. Also shown are the prostate and penis (left panel) and the uterus (right panel). — Anatomy of the male urinary system (left panel) and female urinary system (right panel) showing the kidneys, ureters, bladder, and urethra. Urine is made in the renal tubules and collects in the renal pelvis of each kidney. The urine flows from the kidneys through the ureters to the bladder. The urine is stored in the bladder until it leaves the body through the urethra.

There are three types of bladder cancer that begin in cells in the lining of the bladder. These cancers are named for the type of cells that become malignant (cancerous):

Transitional cell carcinoma: Cancer that begins in cells in the innermost tissue layer of the bladder. These cells are able to stretch when the bladder is full and shrink when it is emptied. Most bladder cancers begin in the transitional cells. Transitional cell carcinoma can be low-grade or high-grade:
- Low-grade transitional cell carcinoma often recurs (comes back) after treatment, but rarely spreads into the muscle layer of the bladder or to other parts of the body.
- High-grade transitional cell carcinoma often recurs (comes back) after treatment and often spreads into the muscle layer of the bladder, to other parts of the body, and to lymph nodes. Almost all deaths from bladder cancer are due to high-grade disease.
Squamous cell carcinoma: Cancer that begins in squamous cells (thin, flat cells lining the inside of the bladder). Cancer may form after long-term infection or irritation.
Adenocarcinoma: Cancer that begins in glandular cells that are found in the lining of the bladder. Glandular cells in the bladder make substances such as mucus. This is a very rare type of bladder cancer.

Cancer that is in the lining of the bladder is called superficial bladder cancer. Cancer that has spread through the lining of the bladder and invades the muscle wall of the bladder or has spread to nearby organs and lymph nodes is called invasive bladder cancer.

See the following PDQ summaries for more information:

Smoking can affect the risk of bladder cancer.

Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk to your doctor if you think you may be at risk for bladder cancer.

Risk factors for bladder cancer include the following:

Using tobacco, especially smoking cigarettes.
Having a family history of bladder cancer.
Having certain changes in the genes that are linked to bladder cancer.
Being exposed to paints, dyes, metals, or petroleum products in the workplace.
Past treatment with radiation therapy to the pelvis or with certain anticancer drugs, such as cyclophosphamide or ifosfamide.
Taking Aristolochia fangchi, a Chinese herb.
Drinking water from a well that has high levels of arsenic.
Drinking water that has been treated with chlorine.
Having a history of bladder infections, including bladder infections caused by Schistosoma haematobium.
Using urinary catheters for a long time.

Older age is a risk factor for most cancers. The chance of getting cancer increases as you get older.

Signs and symptoms of bladder cancer include blood in the urine and pain during urination.

These and other signs and symptoms may be caused by bladder cancer or by other conditions. Check with your doctor if you have any of the following:

Blood in the urine (slightly rusty to bright red in color).
Frequent urination.
Pain during urination.
Lower back pain.

Tests that examine the urine and bladder are used to diagnose bladder cancer.

The following tests and procedures may be used:

Physical exam and health history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Internal exam: An exam of the vagina and/or rectum. The doctor inserts lubricated, gloved fingers into the vagina and/or rectum to feel for lumps.
Urinalysis: A test to check the color of urine and its contents, such as sugar, protein, red blood cells, and white blood cells.
Urine cytology: A laboratory test in which a sample of urine is checked under a microscope for abnormal cells.
Cystoscopy: A procedure to look inside the bladder and urethra to check for abnormal areas. A cystoscope is inserted through the urethra into the bladder. A cystoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
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Cystoscopy. A cystoscope (a thin, tube-like instrument with a light and a lens for viewing) is inserted through the urethra into the bladder. Fluid is used to fill the bladder. The doctor looks at an image of the inner wall of the bladder on a computer monitor.
Intravenous pyelogram (IVP): A series of x-rays of the kidneys, ureters, and bladder to find out if cancer is present in these organs. A contrast dye is injected into a vein. As the contrast dye moves through the kidneys, ureters, and bladder, x-rays are taken to see if there are any blockages.
Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. A biopsy for bladder cancer is usually done during cystoscopy. It may be possible to remove the entire tumor during biopsy.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis depends on the following:

The stage of the cancer (whether it is superficial or invasive bladder cancer, and whether it has spread to other places in the body). Bladder cancer in the early stages can often be cured.
The type of bladder cancer cells and how they look under a microscope.
Whether there is carcinoma in situ in other parts of the bladder.
The patient’s age and general health.

If the cancer is superficial, prognosis also depends on the following:

How many tumors there are.
The size of the tumors.
Whether the tumor has recurred (come back) after treatment.

Treatment options depend on the stage of bladder cancer.

Stages of Bladder Cancer

Key Points

After bladder cancer has been diagnosed, tests are done to find out if cancer cells have spread within the bladder or to other parts of the body.
There are three ways that cancer spreads in the body.
Cancer may spread from where it began to other parts of the body.
The following stages are used for bladder cancer:
Bladder cancer can recur (come back) after it has been treated.

After bladder cancer has been diagnosed, tests are done to find out if cancer cells have spread within the bladder or to other parts of the body.

The process used to find out if cancer has spread within the bladder lining and muscle or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. To stage bladder cancer, the CT scan may take pictures of the chest, abdomen, and pelvis.
MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the brain. This procedure is also called nuclear magnetic resonance imaging (NMRI).
PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. This procedure is done to check whether there are malignant tumor cells in the lymph nodes.
Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
Bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones with cancer and is detected by a scanner.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

Tissue. The cancer spreads from where it began by growing into nearby areas.
Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if bladder cancer spreads to the bone, the cancer cells in the bone are actually bladder cancer cells. The disease is metastatic bladder cancer, not bone cancer.

Many cancer deaths are caused when cancer moves from the original tumor and spreads to other tissues and organs. This is called metastatic cancer. This animation shows how cancer cells travel from the place in the body where they first formed to other parts of the body.

The following stages are used for bladder cancer:

Stage 0 (Noninvasive Papillary Carcinoma and Carcinoma in Situ)

Stage 0 bladder cancer; drawing shows the bladder, ureter, prostate, and urethra. First inset shows stage 0a (also called noninvasive papillary carcinoma) on the inner lining of the bladder. Second inset shows stage 0is (also called carcinoma in situ) on the inner lining of the bladder. Also shown are the layers of connective tissue and muscle tissue of the bladder and the layer of fat around the bladder. — Stage 0 bladder cancer. Abnormal cells are found in the tissue lining the inside of the bladder. Stage 0a (also called noninvasive papillary carcinoma) may look like long, thin growths growing from the lining of the bladder. Stage 0is (also called carcinoma in situ) is a flat tumor on the tissue lining the inside of the bladder.

In stage 0, abnormal cells are found in tissue lining the inside of the bladder. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is divided into stages 0a and 0is, depending on the type of the tumor:

Stage 0a is also called noninvasive papillary carcinoma, which may look like long, thin growths growing from the lining of the bladder.
Stage 0is is also called carcinoma in situ, which is a flat tumor on the tissue lining the inside of the bladder.

Stage I

In stage I, cancer has formed and spread to the layer of connective tissue next to the inner lining of the bladder.

Stage I

In stage II, cancer has spread to the layers of muscle tissue of the bladder.

Stage I

Stage III is divided into stages IIIA and IIIB.

In stage IIIA:
- cancer has spread from the bladder to the layer of fat surrounding the bladder and may have spread to the reproductive organs (prostate, seminal vesicles, uterus, or vagina) and cancer has not spread to lymph nodes; or
- cancer has spread from the bladder to one lymph node in the pelvis that is not near the common iliac arteries (major arteries in the pelvis).
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Stage IIIA bladder cancer. Cancer has spread from the bladder to (a) the layer of fat around the bladder and may have spread to the prostate and/or seminal vesicles in men or the uterus and/or vagina in women, and cancer has not spread to lymph nodes; or (b) one lymph node in the pelvis that is not near the common iliac arteries.
In stage IIIB, cancer has spread from the bladder to more than one lymph node in the pelvis that is not near the common iliac arteries or to at least one lymph node that is near the common iliac arteries.
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Stage IIIB bladder cancer. Cancer has spread from the bladder to (a) more than one lymph node in the pelvis that is not near the common iliac arteries; or (b) at least one lymph node that is near the common iliac arteries.

Stage I

Stage IV is divided into stages IVA and IVB.

In stage IVA:
- cancer has spread from the bladder to the wall of the abdomen or pelvis; or
- cancer has spread to lymph nodes that are above the common iliac arteries (major arteries in the pelvis).
In stage IVB, cancer has spread to other parts of the body, such as the lung, bone, or liver.

Bladder cancer can recur (come back) after it has been treated.

The cancer may come back in the bladder or in other parts of the body.

Treatment Option Overview

Key Points

There are different types of treatment for patients with bladder cancer.
Five types of standard treatment are used:
New types of treatment are being tested in clinical trials.
Treatment for bladder cancer may cause side effects.
Patients may want to think about taking part in a clinical trial.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Follow-up tests may be needed.

There are different types of treatment for patients with bladder cancer.

Different types of treatment are available for patients with bladder cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

Surgery

One of the following types of surgery may be done:

Transurethral resection (TUR) with fulguration: Surgery in which a cystoscope (a thin lighted tube) is inserted into the bladder through the urethra. A tool with a small wire loop on the end is then used to remove the cancer or to burn the tumor away with high-energy electricity. This is known as fulguration.
Radical cystectomy: 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 wall, or when superficial 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. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to reduce urinary symptoms caused by the cancer. When the bladder must be removed, the surgeon creates another way for urine to leave the body.
Partial cystectomy: Surgery to remove part of the bladder. This surgery may be done for patients who have a low-grade tumor that has invaded the wall of the bladder but is limited to one area of the bladder. Because only a part of the bladder is removed, patients are able to urinate normally after recovering from this surgery. This is also called segmental cystectomy.
Urinary diversion: Surgery to make a new way for the body to store and pass urine.

After the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy after surgery to kill any cancer cells that are left. Treatment given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). For bladder cancer, regional chemotherapy may be intravesical (put into the bladder through a tube inserted into the urethra). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Combination chemotherapy is treatment using more than one anticancer drug.

See Drugs Approved for Bladder Cancer for more information.

Immunotherapy

Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This cancer treatment is a type of biologic therapy.

There are different types of immunotherapy:

PD-1 and PD-L1 inhibitor therapy: PD-1 is a protein on the surface of T cells that helps keep the body’s immune responses in check. PD-L1 is a protein found on some types of cancer cells. When PD-1 attaches to PD-L1, it stops the T cell from killing the cancer cell. PD-1 and PD-L1 inhibitors keep PD-1 and PD-L1 proteins from attaching to each other. This allows the T cells to kill cancer cells.
- Pembrolizumab and nivolumab are types of PD-1 inhibitors.
- Atezolizumab, avelumab, and durvalumab are types of PD-L1 inhibitors.

Immune checkpoint inhibitor; the panel on the left shows the binding of proteins PD-L1 (on the tumor cell) to PD-1 (on the T cell), which keeps T cells from killing tumor cells in the body. Also shown are a tumor cell antigen and T cell receptor. The panel on the right shows immune checkpoint inhibitors (anti-PD-L1 and anti-PD-1) blocking the binding of PD-L1 to PD-1, which allows the T cells to kill tumor cells. — Immune checkpoint inhibitor. Checkpoint proteins, such as PD-L1 on tumor cells and PD-1 on T cells, help keep immune responses in check. The binding of PD-L1 to PD-1 keeps T cells from killing tumor cells in the body (left panel). Blocking the binding of PD-L1 to PD-1 with an immune checkpoint inhibitor (anti-PD-L1 or anti-PD-1) allows the T cells to kill tumor cells (right panel).

Immunotherapy uses the body’s immune system to fight cancer. This animation explains one type of immunotherapy that uses immune checkpoint inhibitors to treat cancer.

BCG (bacillus Calmette-Guérin): Bladder cancer may be treated with an intravesical immunotherapy called BCG. The BCG is given in a solution that is placed directly into the bladder using a catheter (thin tube).

Immunotherapy uses the body’s immune system to fight cancer. This animation explains one type of immunotherapy called nonspecific immune stimulation that is used to treat cancer.

See Drugs Approved for Bladder Cancer for more information.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack certain cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do.

The following targeted therapies are approved for patients with bladder cancer that is locally advanced or has spread to other parts of the body:

Enfortumab vedotin is a monoclonal antibody linked to an anticancer drug. This is called an antibody-drug conjugate. It may be used in patients whose cancer has become worse after treatment with an immune checkpoint inhibitor and chemotherapy (cisplatin or carboplatin-based therapy).
Erdafitinib is a tyrosine kinase inhibitor. It may be used in patients with bladder cancer that has certain mutations in the FGFR genes and which has become worse after treatment with chemotherapy (cisplatin or carboplatin-based therapy).

Ramucirumab is a type of targeted therapy that is being studied in combination with chemotherapy for the treatment of bladder cancer. It blocks VEGF to help keep new blood vessels from forming. This may keep cancer cells from growing and may kill them. It is a type of angiogenesis inhibitor and a type of monoclonal antibody.

New types of treatment are being tested in clinical trials.

Information about clinical trials is available from the NCI website.

Treatment for bladder cancer may cause side effects.

For information about side effects caused by treatment for cancer, see our Side Effects page.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. Information about clinical trials supported by NCI can be found on NCI’s clinical trials search webpage. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Bladder cancer often recurs (comes back), even when the cancer is superficial. Surveillance of the urinary tract to check for recurrence is standard after a diagnosis of bladder cancer. Surveillance is closely watching a patient’s condition but not giving any treatment unless there are changes in test results that show the condition is getting worse. During active surveillance, certain exams and tests are done on a regular schedule. Surveillance may include ureteroscopy and imaging tests. See staging tests, above.