What Is Bladder Cancer

What Is Bladder Cancer 2

What Is Bladder Cancer 3

What Is Bladder Cancer 5

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What Is Bladder Cancer?

The Normal Bladder

Your bladder is a hollow pelvic organ with flexible, muscular walls that stores urine. The average adult bladder holds about 2 cups of urine. Urine is made by the 2 kidneys and carried to the bladder by 2 tubes called ureters. The bladder empties the urine through another tube called the urethra. In women, the urethra is a very short tube that ends just in front of the vagina. In men, the urethra is longer. It passes through the prostate gland and the penis, and ends at the tip of the penis.

The wall of the bladder has several layers. A layer of urothelial cells (also called transitional cells) lines the inside of the kidney, ureter, bladder, and urethra. This layer is called the urothelium or transitional epithelium. Beneath the urothelium, there is a thin zone of connective tissue called the lamina propria. The next deeper layer is a wider zone of muscle tissue called the muscularis propria. Beyond this muscle, another zone of fatty connective tissue separates the bladder from other nearby organs. These layers are very important in understanding bladder cancer. As the cancer penetrates through these layers into the wall of the bladder, it becomes harder to treat.

Types of Bladder Cancer

Bladder tumors are grouped into several types by the way they appear under a microscope. The 4 main types of cancers that affect the bladder are:

urothelial carcinoma or transitional cell

carcinoma

squamous cell carcinoma

adenocarcinoma

small cell

These same types of cancer can also grow in the lining of the kidney (called the renal pelvis), the ureters, and the urethra. In fact, patients with bladder cancer sometimes have a similar type of cancer in the lining of the kidneys, ureters, or urethra. Therefore, a complete evaluation of the urinary system is recommended for patients diagnosed with a cancer of the kidney, bladder, ureter, or urethra.
Urothelial cells line the bladder. Urothelial (transitional cell) carcinoma is the most common form of bladder cancer. It accounts for more than 90% of these cancers.

Only about 4% of bladder cancers are squamous cell carcinomas. Under a microscope, the cells look much like cells from skin cancers. Nearly all squamous cell carcinomas are invasive.

Only about 1% to 2% of bladder cancers are adenocarcinomas. The cells have a lot in common with gland-forming cells of intestinal cancers. Nearly all adenocarcinomas of the bladder are invasive.

About 1% of bladder cancers are small cell.
Urothelial carcinomas, squamous cell carcinomas, small cell cancers, and adenocarcinomas may respond differently to radiation and chemotherapy. Treatment recommendations for some patients may be influenced by the type of carcinoma.

Rhabdomyosarcoma is a very rare cancer that can start in the bladder but more often affects other tissues and organs.. It usually affects infants and is seldom found in adults. It is not discussed further in this document but is described in a separate American Cancer Society document, "Rhabdomyosarcoma."

Subtypes of Urothelial Tumors

Not all urothelial tumors are the same. They are divided into several subtypes according to whether they are noninvasive or invasive and whether their shape is papillary or flat.
Noninvasive urothelial tumors: The cancer is only in the innermost layer of the bladder, the urothelium. It has not spread to deeper layers of the bladder.

Invasive urothelial tumors: The cancer has spread from the urothelium to the deeper layers of the bladder wall. In the past, some doctors used this term only when cancer had spread to the thickest and deepest muscle layer of the bladder (called the muscularis propria).

Currently, any bladder cancer not limited to the urothelium is classified as invasive. But it is very important to determine exactly how far into the bladder wall the cancer has invaded. Invasion of the thick, deep muscle layer of the bladder is much more serious than invasion that is limited to the superficial connective tissue layer (lamina propria) or the superficial, thin, muscle layer (muscularis mucosa).

Superficial urothelial tumors: This category includes bladder cancers that are noninvasive as well as some invasive cancers that have not spread deeply into the bladder wall. The cancer may only be in the layers of urothelial cells closest to the inside of the bladder, or it may have also spread to the thin layer of connective tissue (called the lamina propria) just beneath the urothelial cells. Once a cancer has invaded the bladder's main muscle layer, it is not considered superficial.

Papillary urothelial tumors: Papillary tumors have slender finger-like projections that grow into the hollow center of the bladder. They are sometimes said to resemble a branching type of cactus plant. Some papillary urothelial tumors grow only toward the center of the bladder. These are called noninvasive papillary urothelial tumors.

Papillomas are a benign type of papillary urothelial tumor. Since they are not cancerous, these tumors never spread to other parts of the body. They are successfully removed by surgery and rarely grow back. Patients with papillomas very rarely develop another papillary tumor elsewhere in their urinary system.

Papillary urothelial neoplasms of low malignant potential are cancers. These are usually successfully treated by surgical removal. But it is not unusual for patients with these tumors to develop one or more papillary tumors later on in other areas of their urinary system. Most of these other tumors resemble the original tumor, but occasionally the new tumor may be cancerous or even invasive.

Papillary urothelial carcinoma is a papillary tumor showing variable degrees of abnormality of the shape, size, and arrangement of cells. Those with relatively slight abnormality are called low grade. Although they rarely invade into the bladder wall, they often return after surgery. Carcinomas with greater abnormalities, called high-grade carcinomas, are more likely to invade into the bladder wall or even spread to other parts of the body.

Some papillary carcinomas grow inward toward the center and also grow outward into the bladder wall. These are called invasive papillary urothelial carcinomas.

Flat urothelial tumors: Flat urothelial carcinomas do not grow toward the hollow part of the bladder at all. Some of these only involve the layer of cells closest to the inside or the hollow part of the bladder. These are called noninvasive flat urothelial carcinomas. Another name for noninvasive flat urothelial carcinomas is flat carcinoma in situ (CIS). Some flat urothelial carcinomas invade the deeper layers (away from the hollow part), particularly the muscle layer. These are called flat invasive urothelial

What Are the Risk Factors for Bladder Cancer?

A risk factor is anything that increases your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for cancers of the lung, mouth, larynx, kidney, and several other organs. But having a risk factor, or even several, does not mean that you will get the disease.

Many people with one or more risk factors never develop bladder cancer, while others with this disease have no known risk factors. It is important, however, to know about risk factors so that appropriate action can be taken such as changing a health behavior or being monitored closely for a potential cancer. Because the bladder is the final exit from the body for many chemicals, these are the major risk factors for bladder cancer.

Smoking

The greatest risk factor for bladder cancer is smoking. Smokers are more than twice as likely to get bladder cancer as nonsmokers. Smoking causes nearly half of the deaths from bladder cancer among men (48%) and less than a third of bladder cancer deaths in women (28%). Some of the carcinogens (cancer-causing chemicals) in tobacco smoke are absorbed from the lungs and get into the blood. From the blood, they are filtered by the kidneys and concentrated in the urine. These chemicals in the urine damage the urothelial cells that line the inside of the bladder. This damage increases the chance of cancer developing.

Occupational Exposures

Certain industrial chemicals have been linked with bladder cancer. Chemicals called aromatic amines, such as benzidine and beta-naphthylamine, which are sometimes used in the dye industry, can cause bladder cancer.
Other industries that use certain organic chemicals also may put workers at risk for bladder cancer if exposure is not limited by good work place safety practices. The industries carrying highest risks include the makers of rubber, leather, textiles, and paint products as well as printing companies. Other workers with an increased risk of developing bladder cancer include painters, hairdressers, machinists, printers and truck drivers (these because of exposure to diesel fumes).

Cigarette smoking and occupational exposures may act together in the development of bladder cancer. Also, smokers who work with the cancer-causing chemicals noted above have an especially high risk of developing bladder cancer.

Race

Whites are about twice as likely to develop bladder cancer compared with African Americans and Hispanics. The reason for this difference is not well understood. Asians have the lowest incidence of bladder cancer
.
Increasing Age

The risk of bladder cancer increases with age. Over 60% of people with bladder cancer are between 65 and 85 years old.

Gender

Men get bladder cancer at a rate 4 times greater than women.

Chronic Bladder Inflammation

Urinary infections, kidney and bladder stones, and other causes of chronic bladder irritation have been linked with bladder cancer (especially squamous cell carcinoma of the bladder), but they do not necessarily cause bladder cancer. Schistosomiasis (also known as bilharziasis), an infection with a parasitic worm called Schistosoma hematobium that can get into the bladder, is also a risk factor for bladder cancer. Although this parasite is found mostly in Northern Africa, it does cause rare cases of bladder cancer in the United States among people who had been infected by the worm before moving to this country.

Personal History of Bladder Cancer

Urothelial carcinomas can form in many areas in the bladder as well as in the lining of the kidney, the ureters, and urethra. Even when 1 bladder tumor is completely removed, you will have a higher risk of forming another tumor in the same or another portion of the urothelium. For this reason, people who have had bladder cancer need close, routine medical follow-up. People who have family members who have or have had bladder cancer are at increased risk.

Bladder Birth Defects

Before birth, there is a connection between the belly button and the bladder. This connection, called the urachus, normally disappears before birth. If part of this connection remains after birth, it could become cancerous. Cancers that start in the urachus are usually made up of malignant gland cells and are called adenocarcinomas. Cancer starting in this way is rare, causing less than a half of 1% of bladder cancers. However, it does represent about one third of the adenocarcinomas of the bladder, which are also rare.

There is another rare birth defect called exstrophy, which greatly (about 400-fold) increases a person's risk of developing bladder cancer. In exstrophy, the skin, muscle, and connective tissue in front of the bladder fail to close completely so that there is a hole or defect in the wall of the abdomen. This leaves the inside of the bladder exposed to chronic infection, which may eventually lead to formation of an adenocarcinoma of the bladder
.
Genetics

Bladder cancer has been found to be common in some families. This may account for 1% of all cases. People with a mutation of the retinoblastoma gene, which causes them to develop cancer of their eye as infants, have a higher rate of bladder cancer. Many studies have found that people differ in their ability to breakdown chemicals in their body and that this is determined by certain genes they inherit. People who inherit genes that lead to slow breakdown of chemicals are more likely to develop bladder cancer.

Chemotherapy and Radiation Therapy
High doses of cyclophosphamide (Cytoxan), a drug used in the treatment of cancer, and ifosfamide (Ifex), a drug similar to cyclophosphamide, increase the risk of bladder cancer. A typical patient would be one with a lymphoma, which is often cured by chemotherapy regimens that include cyclophosphamide. A drug called mesna is used with these 2 drugs to protect the bladder from irritation and decrease the risk of bladder cancer. People who receive radiation treatment to the pelvis are more likely to develop bladder cancer.

Drinking Water and Arsenic

Arsenic in drinking water has been associated with an increased risk of bladder cancer. Risk depends in large part where you live, and whether your water system meets suggested standards for arsenic content.

Fluid consumption

Low fluid consumption increases risk. People who drink a lot of fluids each day have a lower rate of bladder cancer. This is thought to be due to the fact that they empty their bladders often. By doing this, they donÂ’t allow any chemicals that they might have been exposed to linger.

Do We Know What Causes Bladder Cancer?

We still do not know exactly what causes most bladder cancers. But researchers have found some risk factors and are making progress toward understanding how these factors cause cells in the bladder to become cancerous. (See the section, "What Are the Risk Factors for Bladder Cancer?").
During the past few years, scientists have made great progress in understanding how certain changes in DNA can cause normal bladder cells to grow abnormally and form cancers. DNA is the genetic material that carries the instructions for nearly everything our cells do.

We usually resemble our parents because they passed their DNA on to us. However, DNA affects more than our outward appearance. Some genes (parts of our DNA) contain instructions for controlling when cells grow and divide. Certain genes that promote cell division are called oncogenes. Others that slow down cell division or cause cells to die at the appropriate time are called tumor suppressor genes.

It is known that cancers can be caused by DNA mutations (defects) that activate (turn on) oncogenes or inactivate (turn off) tumor suppressor genes. Some people inherit DNA mutations from their parents that greatly increase their risk for developing breast, ovarian, colorectal and several other cancers. However, bladder cancer does not tend to run in families, and inherited gene mutations are not believed to be a cause of this disease at present.

DNA mutations related to bladder cancer usually develop during life rather than having been inherited before birth. Every time a cell prepares to divide into 2 new cells, it must duplicate its DNA. This process is not perfect and copying errors in the DNA can occur. Fortunately, cells have repair enzymes that proofread DNA. But some errors may slip past, especially if the cells are growing rapidly.

Acquired DNA mutations may result from exposure to cancer-causing chemicals in tobacco smoke that are absorbed into the blood, filtered by the kidneys and released into the urine. Acquired changes in genes, such as the p53 or Rb tumor suppressor genes and the HER-2/neu oncogene, are thought to be important in the development of bladder cancer. Changes of these and similar genes may also be responsible for making some bladder cancers more likely to grow and invade more rapidly than others. Current research in this field is aimed at developing tests that can find bladder cancers at an early stage by recognizing their DNA changes.

Although bladder cancers are not known to result from the inherited mutations as oncogenes or tumor suppressor genes, some people seem to inherit a reduced ability to detoxify (break down) certain types of cancer-causing chemicals. These people are more sensitive to the cancer causing effects of tobacco smoke and certain industrial chemicals. Researchers are developing tests that may help identify such people, but these tests are not routinely available. It is not certain how these test results would be used since doctors recommend that all people avoid tobacco smoke and hazardous industrial chemicals.

Can Bladder Cancer be Prevented?
At this time, there is no certain way to prevent bladder cancer. The best plan is to avoid risk factors when that is possible.

Do Not Smoke

Smoking is believed to cause nearly half the deaths from bladder cancer among men and more than a third among women.

Avoid Occupational Exposure to Certain Chemicals

If you work with
a class of chemicals called aromatic amines, be sure to follow good work safety practices. Industries where these chemicals are commonly used include the makers of rubber, leather, printing materials, textiles, and paint products.

Drink Plenty of Liquids

There is some evidence that drinking large amounts of fluids – mainly water – can lower a personÂ’s risk of bladder cancer.

Diet

A diet high in fruits and vegetable seems to protect against bladder cancer.

Can Bladder Cancer Be Found Early?

Bladder cancer can sometimes be found early. Finding it early improves your chances that it can be treated successfully.

Screening
Screening tests or exams are used to look for a disease in people who have not had that disease before and do not have any symptoms of that disease. Doctors do not specifically screen people for bladder cancer and it is not recommended by any professional organization. A routine urinalysis, however, might find blood in the urine, which can be a sign of bladder cancer. Once a person is diagnosed with bladder cancer, then their doctor will test them periodically to check for recurrence of the cancer.
Risk factors that would justify screening include a previous diagnosis of bladder cancer or certain birth defects of the bladder. People with high work-related exposure to certain chemicals might also be screened.

Blood in the urine is often the first sign of bladder cancer. Although large amounts of blood are readily visible, small amounts can be found by examining the urine under a microscope or by a simple chemical test that is available in any doctorÂ’s office. Blood in the urine is usually caused by benign conditions such as infections. But a small percentage of people with blood in their urine have bladder cancer.

Another screening test for people suspected of bladder cancer is to examine the urine for cancer cells. This is not very reliable though. A new test for a substance in the urine called NMP22 has been successful in about 50% of people at high risk for bladder cancer. Unfortunately this means that the cancers in other half of the people were missed.

If you don't have any known risk factors, prompt attention to bladder symptoms is the best advice for finding bladder cancer in its earliest, most treatable stages.

How Is Bladder Cancer Diagnosed?

If there is a reason to suspect you might have bladder cancer, the doctor will use one or more methods to find out if this disease is really present. If it is, then the extent of spread (stage) of the disease will also be determined.

Signs and Symptoms of Bladder Cancer

Blood in the urine: In most cases, blood in the urine (hematuria) is the first warning signal of bladder cancer. Sometimes, there is enough blood to color the urine. Depending on the amount of blood, the urine may be very pale yellow-red or, less often, darker red. In other cases, the color of the urine is normal but small amounts of blood can be found by urine tests done because of other symptoms or as part of a general medical checkup.

Blood in the urine is not a sure sign of bladder cancer. It may also be caused by infections of the kidneys, bladder, or urethra, other benign kidney diseases, benign tumors of the kidney, bladder or ureter, and kidney or bladder stones. Blood may be present one day and absent the next, with the urine remaining clear for weeks or months. With bladder cancer, blood eventually reappears. Usually the early stages of bladder cancer cause bleeding but little or no pain.

Change in bladder habits: Having to urinate more often than usual or having a feeling of needing to go but not being able to is also a symptom of bladder cancer. Rarely, people with bladder cancer notice burning during urination. However, these symptoms can also be caused by benign conditions such as an infection or benign tumors, bladder stones, an overactive bladder, or an enlarged prostate.

Medical History and Physical Exam
The first step is for your doctor to take a complete medical history to check for risk factors and symptoms. A physical exam provides other information about signs of bladder cancer and other health problems. The doctor might examine the rectum and vagina (in women) to determine the size of a bladder tumor and to see if and how far it has spread.

Cystoscopy

A cystoscope is a slender tube with a lens and a light. It is placed into the bladder through the urethra. It permits the doctor to view the inside of the bladder. Some sort of anesthesia is used. This is usually local, such as an anesthetic gel, but can be general or spinal. If suspicious areas or growths are seen, a small piece of tissue is removed and examined (biopsy ).

Laboratory Tests to Diagnose Bladder Cancer

Urine cytology: The urine is examined under a microscope to look for cancerous or precancerous cells. Cytology can also be done on bladder washings. Bladder washing samples are taken by placing a salt solution into the bladder through a catheter (tube) and then removing the solution for microscopic testing. If the test does not find cancer, this doesnÂ’t mean there isnÂ’t any there. The test can sometimes fail to find cancer.

Urine culture: A urine culture is done to rule out an infection. Infections and bladder cancers can sometimes cause similar symptoms. A sample of urine is tested in the lab to see if bacteria are present. It may take 48 to 72 hours to get the results of this test.
Biopsy: A sample of bladder tissue is removed from a suspicious area or growth, using instruments operated through the cystoscope. The sample is examined under the microscope. This can identify bladder cancers and tell what type of cancer (urothelial carcinoma, squamous cell carcinoma, adenocarcinoma, etc.) is present. It can also tell how deeply the cancer has penetrated.

Bladder cancers are graded, from 1 to 4, based on how they look under the microscope.

Low-grade (1) cancers look more like normal bladder tissue. They usually have a good prognosis. These are called well-differentiated cancers.

Grade 2 cancers are called moderately differentiated.

High-grade (3-4) cancers look less like normal tissue. They are more likely to invade the bladder wall and to spread outside the bladder and tend to be associated with a less favorable prognosis. These cancers are called either poorly differentiated or undifferentiated.
It is not unusual for people with one bladder cancer to develop additional cancers in other areas of the bladder or elsewhere in the urinary system. For this reason, the doctor may biopsy several different areas of the bladder lining.

Bladder tumor marker studies: These are chemical or immunologic (using antibodies) tests to find specific substances released by bladder cancer cells into the urine such as NMP22 discussed in the section, "Can Bladder Cancer Be Found Early?" Another more commonly used test is the ImmunoCyt test. This is another test for cancer-related substances in the urine and may be more sensitive than cytology for certain cancers. Some doctors find these tests useful, but most feel more research is needed before they should be used routinely. For more information, see the section, "What's New in Bladder Cancer Research and Treatment?"

Imaging Tests

Intravenous pyelogram (IVP): In this procedure, also known as intravenous urography an x-ray is taken after injecting a dye through a vein into the bloodstream. This dye reaches the kidneys, ureters, and bladder and more clearly outlines these organs on x-rays. This is important because the blood in the urine may come from anywhere in the urinary tract, not just the bladder.

Retrograde pyelography: Like the IVP, this test uses special dye to make the lining of the bladder, ureters, and kidneys easier to see on x-rays. The difference is that in retrograde pyelography the dye is injected through a catheter placed with a cystoscope into the ureter rather than into a vein.

Chest x-ray: A chest x-ray is done to look for any mass or spot on the lungs that might be a metastatic tumor, if it is suspected that the bladder cancer has spread distantly.

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body (think of a loaf of sliced bread). The machine will take pictures of multiple slices of the part of your body that is being studied. Often after the first set of pictures is taken you will receive an intravenous injection of a "dye" or radiocontrast agent that helps better outline structures in your body. A second set of pictures is then taken.

CT scans take longer than regular x-rays and you will need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. The newest CT scanners take only seconds to complete the study. Also, you might feel a bit confined by the ring-like equipment youÂ’re in when the pictures are being taken.

The contrast "dye" is injected through an IV line. Some people are allergic to the dye and get hives, a flushed feeling, or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell your doctor if you have ever had a reaction to any contrast material used for x-rays. If you have, you may need medicine before you can have such an injection during your test.
You may also be asked to drink a contrast solution. This helps outline your intestine if your doctor is looking at organs in your abdomen. The CT scan will provide precise information about the size, shape, and position of a tumor, and can help find enlarged lymph nodes that might contain cancer.

Magnetic resonance imaging (MRI) scans: This procedure is similar to a CT scan, but uses powerful magnets and radio waves instead of x-rays to take detailed cross-sectional images. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body.

If your doctor suspects that the cancer has spread beyond the bladder, MRI scans are sometimes used to find cancer in tissues next to the bladder, in nearby lymph nodes, or in distant organs. In such cases, either a CT or MRI scan may be used.

A contrast material might be injected just as with CT scans but is used less often. MRI scans take longer – often up to an hour. Also, you have to be placed inside a tube-like piece of equipment, which is confining and can upset people with claustrophobia (fear of enclosed spaces). The machine makes a thumping noise that you may find annoying. Some places will provide headphones with music to block this out. MRI images are particularly useful in examining pelvic tumors. MRI scans are also helpful in finding cancer that has spread to the brain or spinal cord.

Ultrasound: This test, also known as ultrasonography, uses sound waves to create "echoes" of internal organs. The pattern of echoes reflected by tissues can be useful in determining the size of a bladder cancer and whether it has spread beyond the bladder.

Bone scans: In this imaging test, a small amount of a radioactive substance is injected into a vein. This substance accumulates in areas of bone where the cancer has spread. These areas can then be looked at with a special camera. However, other cancers and some non-cancerous bone diseases can also cause abnormal bone scan results.

Positron Emission Tomography (PET) scans: PET scanning is a technique that uses radioactive substances to show areas of cancer that may not otherwise be seen on more usual tests such as CT scan or MRI. It may also be able to distinguish benign tumors or masses from cancerous ones.

Although PET scans are being used as part of research projects in bladder cancer, it is not yet certain how valuable they are in helping to manage the care of patients with bladder cancer.

How Is Bladder Cancer Staged?

Staging is the process of gathering information from exams and diagnostic tests to determine how widespread a cancer is. The stage of a cancer is one of the most important factors in selecting treatment options. It is also helpful in determining the patient's prognosis (outlook).

Biopsy samples and any tissue removed by a surgical operation are examined and also used to determine the extent of cancer spread. Doctors examining the biopsy sample are especially interested in noting whether there is any spread of cancer cells into the bladder's muscle layers.

Certain imaging tests such as a chest x-ray, an intravenous pyelogram or retrograde pyelogram, CT or MRI scan or ultrasound exam may be done to find spread to tissues near the bladder, to nearby lymph nodes, and to distant organs. If imaging tests find a mass in the liver, lungs, or other distant organs, or if lymph nodes near the bladder appear too large, tissue samples will be taken.
Although imaging tests can suggest spread of cancer, checking a tissue sample under a microscope is the only way to be sure. These samples can be taken during a surgical operation. A needle biopsy is often able to take samples without the need for an operation. CT scans can be used to accurately guide the biopsy needle into the enlarged lymph nodes or into liver or lung masses.

A staging system is a standardized way in which the cancer care team describes the extent to which the cancer may have spread. The staging system of the American Joint Committee on Cancer (AJCC), sometimes also known as the TNM system, is the most common system used for bladder cancer.

The letter T followed by a number from 1 to 4 describes the extent of the tumor's invasion into the bladder wall and to nearby tissues. Higher T numbers indicate more extensive invasion.

The letter N followed by a number from 0 to 3 indicates whether the cancer has spread to lymph nodes near the bladder and, if so, how large the lymph nodes are. Lymph nodes are normally bean-sized collections of immune system cells that help fight infections and cancers.

The letter M followed by a 0 or 1 indicates whether or not the cancer has spread to distant organs (for example, the lungs or bones) or to lymph nodes that are not near the bladder.

Once a patient's T, N, and M categories have been determined, this information is combined in a process called stage grouping to determine a patient's disease stage. This is expressed in stages by the number 0 and in Roman numerals ranging from I to IV, with Stage 0 (the least serious or earliest stage) and Stage IV (the most serious or advanced stage).

The next section summarizes features of the 2002 version of AJCC (American Joint Committee on Cancer) stages for bladder cancer. It is followed by a more detailed discussion of specific T, N, and M categories and how they are grouped to determine a bladder cancer's stage.

Some doctors may also use other staging systems that use the letters A, B, C and D to describe the extent of a bladder cancer. If you have bladder cancer, ask your cancer care team to explain its stage. In this way, you will be able to make informed choices about your treatment.

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