Bladder Cancer Diagnosis and Staging

November 25, 2024

This page was reviewed under our medical and editorial policy by Kevin G. Chan, M.D., clinical professor, division of urology and urologic oncology, Department of Surgery, City of Hope^® Cancer Center Duarte

Bladder cancer may be diagnosed using a variety of tests. If bladder cancer is suspected, a urologist or urologic oncologist — experts in diagnosing and treating disease of the male and female urinary tract — may order a series of tests to see if cancer is present. If so, additional tests may be performed to determine the type and stage of the disease.

This guide aims to help patients learn more about bladder cancer diagnosis and staging.

How is Bladder Cancer Detected and Diagnosed?

Once the patient notices possible bladder cancer symptoms, or as part of a routine examination, the doctor may use the following tests to look for bladder cancer.

Physical exam: During a physical examination, a doctor reviews the patient’s medical history, discusses risk factors for bladder cancer and examines the patient for any symptoms of disease. For an internal exam, the doctor inserts gloved, lubricated fingers into the vagina or rectum to feel for lumps in the bladder.

Urine lab test: A sample of the patient’s urine is taken and examined for cancerous or precancerous cells or biomarkers indicating bladder cancer. Several types of urine tests may be used.

• A urine culture test looks for infection. Infections in the urinary tract may have symptoms similar to bladder cancer. When this test is performed, bacterial growth is tested in the lab, helping to identify infection, which may help rule out a cancer diagnosis. This may take a couple of days to complete.
• A urinalysis test is routine, and it examines the appearance, odor and pH (acidity) levels, and tests for substances such as blood, proteins and bacteria in the urine sample. Results are available almost right away.
• Urine cytology tests look for cancerous or precancerous cells under a microscope.
• Urine tumor marker tests look for specific markers in the urine that are produced by cancer cells or by the body when cancer cells are present.

Biopsy: Surgical removal of suspicious tissues for further examination.

Cystoscopy: A thin, flexible tube (cystoscope) equipped with a lens and light source is inserted into the urethra and guided into the bladder. The bladder is then filled with fluid and examined for abnormalities. If suspicious tissues are seen, they may be biopsied for further examination. Localized, spinal or general anesthesia may be administered prior to this procedure.

Fluorescence cystoscopy: Also known as blue light cystoscopy, this enhanced form of cystoscopy uses a light-activated drug. The drug is taken up by cancer cells and glows when a blue light is shone upon it, allowing for easier detection of cancerous areas.

Tests for Bladder Cancer

If cancer is found, additional tests are performed to determine the type of bladder cancer and stage of disease.

Intravenous pyelogram (IVP): Also called intravenous urogram (IVU), this procedure first injects a special dye into the vein. The dye then coats the interior lining of the urinary tract and an X-ray is taken to see if there are any tumors in the bladder, kidneys or ureters.

Retrograde pyelogram: During this test, dye is injected at the opening of the ureter in the bladder cystoscopically. It is often used for patients who are allergic to IV contrast by allowing the dye to light up the urinary tract without getting absorbed systemically.

Commuted tomography (CT or CAT) scan: This test involves taking a series of X-ray images at different angles to form a computer-generated image, which determines tumor size, location and number. CT scans may also be used to guide a biopsy.

CT/PET scan: This test combines a CT scan with a positron emission tomography (PET) scan, allowing the care team to look for cancer and its possible spread.

Ultrasound: High energy sound waves are used to create images of the bladder, and it may be also be used to guide a biopsy.

Magnetic resonance imaging (MRI) urogram: This procedure images the bladder, ureters and kidneys using a powerful magnet, radio waves and a computer. A biopsy may be taken at the same time if the MRI images show any abnormalities.

Lymph node biopsy: Removal and examination of lymph nodes in the pelvic region to see if the cancer has spread.

Bone scan: A procedure using a small amount of radioactive material to determine if bladder cancer cells have spread to the bones

Genomic testing: The cancerous tissue is tested to see if it exhibits certain genetic mutations, which can be used to determine better treatments.

Based on the results of these tests, the bladder cancer is then staged according to its size, number of lymph nodes affected and whether it has spread to nearby or distant organs. Bladder cancer is also evaluated by “grades” based on how much it resembles normal bladder cells and how aggressive it grows.

Bladder Cancer Stages

After bladder cancer has been diagnosed, tests are performed to determine the size of the tumor and to see if the cancer cells have spread within the bladder or to other parts of the body. This results in each cancer being assigned a stage. There are three ways that cancer spreads: into nearby tissue, into the lymph vessels to other parts of the body and into blood vessels to other parts of the body.

Bladder cancer is staged using the American Joint Committee on Cancer (AJCC) TNM system. TNM stands for tumor, nodes and metastasis.

Tumor: Doctors examine the size of the bladder cancer tumor and determine if it has spread into nearby tissue.

Nodes: Nodes is a reference to lymph nodes, part of the body’s immune system. Doctors test to see if the cancer has spread into lymph nodes close to the bladder.

Metastasis: Checking for metastasis lets doctors determine if the cancer has spread away from the bladder into distant areas of the body. When bladder cancer metastasizes (spreads), it may move into the liver or lungs.

The following stages are used to describe the location and extent of bladder cancer.

Stage 0 (papillary carcinoma and carcinoma in situ): In Stage 0, abnormal cells are found in tissue lining the inside of the bladder, but have not spread into the bladder wall. These abnormal cells may later become cancer and spread into normal tissue nearby. It is also known as noninvasive bladder cancer.

• Stage 0a: This stage grouping is called noninvasive papillary carcinoma. Cancer cells are found within the bladder’s lumen, the open space that urine passes through, but they are not found within the bladder wall.
• Stage 0is: This grouping is known as carcinoma in situ. Cancer cells are only found in the bladder’s inner lining.

Stage 1: Cancer has formed and spread to the layer of connective tissue next to the inner lining of the bladder, but not into the muscle of the bladder wall. It is a type of non-muscle-invasive bladder cancer.

Stage 2: Cancer has spread to layers of muscle tissue in the bladder, so it is a type of muscle-invasive bladder cancer. However, it has not spread into surrounding tissue.

Stage 3: Cancer has spread from the bladder to the layer of fat surrounding it and may have spread to the reproductive organs (prostate, seminal vesicles, uterus or vagina). Stage 3 is considered locally advanced bladder cancer.

• Stage 3a: In Stage 3a, cancer has spread out of the bladder and into the surrounding fatty tissue. It may have also spread into the uterus, vagina, prostate or seminal vesicles, but not into nearby lymph nodes or the pelvic wall. Or, cancer may also be classified as Stage 3a if it has spread into one nearby lymph node close to the pelvis, but not the pelvic or abdominal wall or distant body sites.
• Stage 3b: The cancer has spread to more than one lymph node, which may or may not be near the major arteries in the pelvis.

Stage 4: Cancer has spread from the bladder to the wall of the abdomen or pelvis, one or more lymph nodes and/or other parts of the body, such as the lungs, liver or bones. Stage 4 is also referred to as metastatic bladder cancer.

• Stage 4a: The cancer has spread into the abdominal or pelvic wall, but not to distant sites. Or, cancer may have spread into the abdominal or pelvic wall and possibly to nearby lymph nodes, but not to distant body sites.
• Stage 4b: The cancer has spread into at least one distant organ, which may include the liver, lungs or bones.

What Are the Current Screening Guidelines for Bladder Cancer?

There are currently no screening guidelines for bladder cancer, since no screenings have been shown to lower the risk of dying from bladder cancer for people of average risk. However, a physician may recommend screening if the patient is at a high risk of developing bladder cancer, due to:

• Specific genetic mutations
• Birth defects
• Workplace chemical exposure