Diagnosing bladder cancer

Diagnosis

If your doctor suspects you have bladder cancer, they will examine you and arrange tests. The tests you have may include:

• general tests to check your overall health
• tests to find cancer
• further tests to see if the cancer has spread (metastasised).

Some tests may be repeated during and after treatment to see how the treatment is working. If you feel anxious waiting for test results, it may help to talk to a friend or family member, or call Cancer Council 13 11 20.

General tests

The first tests you have may be an internal examination and blood and urine tests. Sometimes you won’t need an internal examination until after bladder cancer has been diagnosed.

Internal examination

As the bladder is close to the rectum and vagina, your doctor may do an internal examination by inserting a gloved finger into the rectum or vagina to feel for anything unusual. Some people find this test embarrassing or uncomfortable, but it takes less than a minute.

Blood and urine tests

Your doctor may take blood samples to check your overall health. You will also be asked for a urine sample, which will be checked for blood and bacteria (called urinalysis). If you have blood in your urine, you may need to collect samples of your urine over 3 days. These samples will be checked for cancer cells (called urine cytology).

Tests to find cancer in the bladder

The main test to look for bladder cancer is a cystoscopy. This procedure lets your doctor look closely at the bladder lining (urothelium). Other tests can also give your doctor information about the cancer. These may include an ultrasound before the cystoscopy, a tissue sample (biopsy) taken during a cystoscopy, and a CT or MRI scan.

Ultrasound

An ultrasound uses soundwaves to create a picture of the bladder. This scan is used to show if cancer is present and how large it is, but an ultrasound can’t always find small tumours.

Your medical team will usually ask you to drink lots of water before the ultrasound so you have a full bladder. This makes the bladder easier to see on the scan. After the first scan, you will go to the toilet and empty your bladder, then the scan will be repeated.

During an ultrasound, you will lie on a bench and uncover your abdomen (belly). A cool gel will be spread on your skin, and a small handheld device called a transducer will be moved across your abdominal area. The transducer creates soundwaves that echo when they meet something solid, such as an organ or tumour. A computer turns the soundwaves into a picture. Having an ultrasound is painless and usually takes 15–20 minutes. Not all people will have an ultrasound. Sometimes, a CT scan is the first scan you will have.

CT Scan

A CT (computerised tomography) scan uses x-rays and a computer to create a detailed picture of the inside of the body. A scan of the urinary system may be called a CT urogram, CT IVP (intravenous pyelogram) or a triple-phase abdomen and pelvis CT – these are different names for the same test. Some people have a CT scan of other areas of the body to see if the cancer has spread.

CT scans are usually done at a hospital or a radiology clinic. When you make the appointment for the scan, you will be given instructions to follow about what you can eat and drink before the scan.

As part of the procedure, a dye (the contrast) is injected into one of your veins. The dye travels through your bloodstream to the kidneys, ureters and bladder, and helps show up abnormal areas more clearly.

The scan is usually done 3–4 times: before the dye is injected, immediately afterwards, and once or twice a short time later. The dye may make you feel hot all over and cause some discomfort in the abdomen and a feeling of having passed urine. Symptoms should ease quickly but tell the person doing the scan if you feel unwell.

During the scan, you will need to lie still on an examination table that moves in and out of the scanner, which is large and round like a doughnut. The whole procedure takes 30–45 minutes.

MRI Scan

Less commonly, your doctor may recommend an MRI (magnetic resonance imaging) scan to check for bladder cancer. This scan uses a powerful magnet and radio waves to create detailed cross-sectional pictures of organs in your abdomen.

Before the scan, let your medical team know if you have a pacemaker or any other metallic object in your body. If you do, you may not be able to have an MRI scan, although some newer devices are safe to go into the scanner. Also ask what the MRI will cost, as Medicare usually does not cover this scan for bladder cancer.

Before the MRI, you may be injected with a dye to help make the pictures clearer. You will then lie on an examination table inside a large metal tube that is open at both ends. The scan is painless, but the noisy, narrow machine makes some people feel anxious or claustrophobic. If you think you could become distressed, mention this to your medical team. You may be given a mild sedative to help you relax. The MRI scan takes 30–90 minutes.

Cystoscopy

The next test is often a cystoscopy. This is done using a cystoscope (a thin tube with a light and camera on the end), which will be either flexible or rigid (a tube that does not bend). A flexible cystoscopy allows the doctor to see if there is a tumour, while a rigid cystoscopy or transurethral resection of bladder tumour (TURBT) is needed to remove a tumour. If the initial scans suggest there may be a tumour, you will usually have a rigid cystoscopy.

Flexible cystoscopy – This procedure is done under a local or general anaesthetic, with a gel squeezed into the urethra to numb the area. The cystoscope is put through your urethra and into the bladder. The camera projects images onto a monitor so the doctor can see inside the bladder. A flexible cystoscopy usually takes only a few minutes. For several days after the procedure, you may see some blood in your urine and feel mild discomfort when urinating.

Rigid cystoscopy and biopsy – This is done in hospital under general anaesthetic, usually as a day procedure. It takes about 30 minutes. 

The cystoscope is put through your urethra into the bladder. If a small tumour is found, the doctor will put some instruments into the cystoscope and remove a sample of tissue. This will be tested for signs of cancer (a biopsy). The biopsy results are usually available in 5–7 days. If a larger tumour is found, you may have a procedure called a transurethral resection of bladder tumour (TURBT).

After the cystoscopy, you may have some urinary symptoms, such as going to the toilet frequently or urgently, or even having trouble controlling your bladder (incontinence). These symptoms will usually settle in a few hours. Keep drinking fluids and stay near a toilet.

Transurethral resection of bladder tumour (TURBT)

This procedure is done in hospital under general anaesthetic and takes up to 45 minutes. In some cases, a TURBT may be the only procedure needed to treat the cancer.

How TURBT is done – The rigid cystoscope is passed through the urethra into the bladder so the surgeon can see the inside of your bladder on a monitor. The surgeon may remove the tumour through the urethra using a wire loop on the end of the cystoscope. Other methods for destroying the cancer cells include burning the base of the tumour with an electrical current (fulguration) or using a high-energy laser. A TURBT does not involve any cuts to the outside of the body.

The removed tissue will be examined for signs of cancer. Results are usually available in 5–7 days. See the next page for more information about what to expect after a TURBT.

What to expect after a TURBT

Most people who have a TURBT stay in hospital for 1–2 days. Your body needs time to recover and heal after the surgery.

Having a catheter

You may have a thin, flexible tube (catheter) put in your bladder to drain your urine into a bag. The catheter may be connected to a system that uses saline (salt water) to wash the blood and blood clots out of your bladder. This is called bladder irrigation. When your urine looks clear, the catheter will be removed and you will be able to go home. If the tumour is small, you may not need a catheter and you may be discharged from hospital on the same day.

Recovery at home

When you go home, avoid any heavy lifting or vigorous exercise for about 3–4 weeks. If you were taking blood-thinning drugs before the procedure, talk to your doctor about when you can restart them.

Side effects

Side effects may include blood in the urine, passing urine more often and bladder infections. It is normal to see some blood in your urine for up to 2 weeks. Talk to your doctor if you have any concerns.

Flushing the bladder

It is important to drink lots of water to flush the bladder of blood and keep the urine clear.

When to get help

Contact your medical team immediately if you feel cold, shivery, hot or sweaty; have burning or pain when urinating; need to urinate often and urgently; pass blood clots; or have difficulty passing urine.

Futher tests

You may need other imaging tests such as a PET–CT scan, radioisotope bone scan or x-rays to show if and how far the cancer has spread.

PET–CT scan

A PET (positron emission tomography) scan combined with a CT scan is a specialised imaging test. It may be used to find bladder cancer that has spread to lymph nodes or other areas of the body.

Clinic staff will tell you how to prepare for a PET–CT scan, particularly if you have diabetes. Before the scan, you will be injected with a glucose solution containing a small amount of radioactive material. Cancer cells show up brighter on the scan because they take up more glucose solution than normal cells do. You will be asked to sit quietly for 30–90 minutes as the glucose moves through your body, then you will be scanned. 

Radioisotope bone scan

A radioisotope scan is used to see whether the cancer has spread to the bones. It may be called a whole-body bone scan (WBBS) or a bone scan.

Before you have the scan, a tiny amount of radioactive dye is injected into a vein, usually in your arm. You will need to wait for a few hours while the dye moves through your bloodstream to your bones. The dye collects in areas of abnormal bone growth. Your body will be scanned with a machine that detects radioactivity. A larger amount of radioactivity will show up in any areas of bone affected by cancer cells. 

The scan is painless and takes less than an hour. Afterwards, you need to drink plenty of fluids and urinate frequently to flush the radioactive dye from your body. This usually takes a few hours. If you care for young children, avoid close contact with them for a short time after the scan.

X-rays

You may need x-rays if a particular area looks abnormal in other tests or is causing symptoms. A chest x-ray can check the health of your lungs and look for signs the cancer has spread. Sometimes, people will have a CT scan instead of an x-ray.

Staging bladder cancer

The tests described in this chapter help show whether you have bladder cancer, how far the cancer has grown into the layers of the bladder, and if the cancer has spread outside the bladder. This is called staging. 

The staging system most commonly used is the TNM system, which stands for tumour-node-metastasis. Using this information, the doctor may describe the cancer as:

Superficial bladder cancer – This is also called non-muscle-invasive bladder cancer or NMIBC. The cancer cells are found only in the inner lining of the bladder (urothelium) or the next layer of tissue (lamina propria) and haven’t grown into the deeper layers of the bladder wall. 

Muscle-invasive bladder cancer (MIBC) – The cancer has spread through the urothelium and lamina propria into the layer of muscle (muscularis propria), or sometimes through the bladder wall into the surrounding fatty tissue. MIBC can also sometimes spread to lymph nodes close to the bladder.

Advanced bladder cancer – The cancer has spread (metastasised) outside of the bladder into distant lymph nodes or other organs of the body. 

TNM staging system

The most common staging system for bladder cancer is the TNM system.  In this system, letters and numbers are used to describe the cancer, with higher numbers indicating larger size or spread.

T stands for tumour – Ta, Tis and T1 are superficial bladder cancer, while T2, T3 and T4 are muscle-invasive bladder cancer.

N stands for nodes – N0 means the cancer has not spread to the lymph nodes; N1, N2 and N3 indicate it has spread to lymph nodes. NX means it is unknown.

M stands for metastasis – M0 means the cancer has not spread to distant parts of  the body; M1 means it has spread to distant parts of the body. MX means it is unknown.

Some doctors put the TNM scores together to produce an overall stage, from stage 1 (earliest stage) to stage 4 (most advanced).

Grade and risk category

The biopsy and/or TURBT results will show the grade of the cancer. This is a score that describes how quickly a cancer might grow. 

Knowing the grade helps your urologist predict how likely the cancer is to come back (recur) or grow into deeper layers (progress), and if you will need further treatment after surgery. The grade may be described as:

Low grade – The cancer cells look similar to normal bladder cells and are usually slow-growing. They are less likely to invade and spread.

High grade – The cancer cells look very abnormal and grow quickly; they are more likely to spread both into the bladder muscle and outside the bladder.

In superficial bladder cancers, the grade may be low or high, while almost all muscle-invasive cancers are high grade. Carcinoma in situ (stage Tis in the TNM system) is a flat, high-grade tumour that needs to be treated quickly to prevent it invading the muscle layer.

Risk category – Based on the stage, grade and other features, a superficial bladder cancer will also be classified as having a lower or higher risk of returning after treatment or spreading into the muscle layer. Knowing the risk category will help your doctors work out which treatments to recommend.

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis with your doctor, but it is not possible for anyone to predict the exact course of the disease.

In general, the earlier bladder cancer is diagnosed, the better the outcome. To work out your prognosis, your doctor will consider:

• your test results
• the type of bladder cancer
• the stage, grade and risk category
• how well you respond to treatment
• other factors such as your age, fitness and medical history.

Key points about diagnosing bladder cancer

General tests

General tests may include:

• an internal examination – the doctor inserts a gloved finger into the rectum or vagina to feel for anything unusual
• blood and urine tests.

Main tests

The main test to diagnose bladder cancer is a cystoscopy. The doctor will view the bladder by inserting a thin tube with a light and camera (cystoscope) through the urethra. Different types of cystoscope may be used:

• a flexible cystoscopy can be done with local or general anaesthetic
• a rigid cystoscopy is done under general anaesthetic in hospital and may include a biopsy and/or a transurethral resection of bladder tumour (TURBT). 

Your doctor may also arrange:

• an ultrasound – a scan that uses soundwaves to create pictures of the bladder
• CT and MRI scans – these involve an injection of dye into the body.

Further tests

To check if cancer has spread to other parts of the body, you may have:

• a PET–CT scan
• a radioisotope bone scan
• x-rays.

Stage, grade and risk category

• Bladder cancer is given a stage to describe how much cancer there is and whether it has spread.
• The grade describes how quickly the cancer might grow.
• The risk category describes how likely the cancer is to return after treatment.