Diagnosing bladder cancer

Monday 1 February, 2016

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On this page: General tests | Tests to find cancer in the bladder | Further tests | Prognosis | Staging bladder cancer | Grading bladder cancer


To diagnose bladder cancer, your general practitioner (GP) may do some general tests and then refer you to a specialist for additional tests. Further tests may be needed to work out whether the cancer has spread beyond the bladder. The tests you have will depend on your specific situation. Some tests may be repeated during or after treatment to see how the treatment is working.

Waiting for test results can be a stressful time. It may help to talk to a friend or family member or to a health care professional, or you can call Cancer Council 13 11 20.

General tests

To investigate abnormal symptoms, your doctor may perform an internal examination and arrange certain blood and urine tests.

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. Although some people find this test embarrassing or uncomfortable, it is painless and only takes a few seconds.

Blood and urine tests

Blood samples may be taken to check your general health. You will be asked to give a urine sample, which will be checked for blood and bacteria – this test is called a urinalysis. You may also be asked to give three separate urine samples, which will be sent to a laboratory to look for cancer cells (cytology).

Tests to find cancer in the bladder

To determine the position of the cancer in the bladder, you will need various tests. These may include an ultrasound, a CT or MRI scan, a flexible cystoscopy, and a rigid cystoscopy and biopsy.

Ultrasound

An ultrasound scan uses soundwaves to create a picture of your organs. It is used to show if cancer is present and how large it is. An ultrasound can’t always find small tumours, so your doctor may do further tests.

Your medical team will usually ask you to have a full bladder for the ultrasound. After the first scan, you will then be asked to empty your bladder and the scan will be repeated.

During an ultrasound scan, you will uncover your abdomen and lie on an examination table. A gel will be spread on your skin and a device called a transducer will be moved across your abdomen. 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. Ultrasound scans are painless, and they usually take 15–20 minutes.

CT scan

A CT (computerised tomography) scan uses x-ray beams to take many pictures of the inside of your body and then compiles them into one detailed, cross-sectional picture. If the scan is checking for bladder cancer, it may be called a CT-IVP (intravenous pyelogram) or a triple-phase abdomino-pelvic CT.

CT scans are usually done at a hospital or a radiology clinic. Your doctor will give you instructions about eating and drinking before the scan. As part of the procedure, a dye, sometimes called the contrast, will be injected into one of your veins. The dye travels through your bloodstream to the kidneys, ureters and bladder, and shows up any abnormal areas. You will then lie on an examination table and pass through the CT scanner, which is large and round like a doughnut.

The scan is usually done three times: once before the dye is injected, once immediately afterwards, and then again a bit later. The dye may make you feel flushed and cause some discomfort in your abdomen. Symptoms should ease quickly, but tell the doctor if you feel unwell. The whole procedure takes 30–45 minutes.

The dye used in a CT scan usually contains iodine. If you have had an allergic reaction to iodine or dyes during a previous scan, tell your medical team beforehand. You should also let them know if you are diabetic, have kidney disease or are pregnant.

MRI scan

Less commonly, an MRI (magnetic resonance imaging) scan may be used to check for bladder cancer. This scan uses magnetic waves to create detailed cross-sectional pictures of organs in your abdomen. You should let your medical team know if you have a pacemaker, as the magnetic waves can interfere with some pacemakers.

For an MRI, you may be injected with a dye that highlights the organs in your body. You will then lie on an examination table inside a large metal tube that is open at both ends.

The noisy, narrow machine makes some people feel anxious or claustrophobic. If you think you may become distressed, mention it beforehand to your medical team. You may be given a mild sedative to help you relax or you might be able to bring someone into the room with you for support. You will usually be offered headphones or earplugs.

The MRI scan may take between 30 and 90 minutes.

Flexible cystoscopy

Cystoscopy is a common procedure for diagnosing bladder cancer. A slender hollow tube with a light and a camera, called a cystoscope, is used to examine the inner lining of the bladder. The cystoscope may be flexible or rigid.

In many cases, your first cystoscopy will use a flexible cystoscope and will be done under local anaesthetic. For this procedure, anaesthetic jelly is passed down the urethra to numb the area. The cystoscope is inserted through your urethra and into the bladder to examine the whole of the inside lining.

If the test finds abnormal tissue, you will usually be asked to come back for a rigid cystoscopy under general anaesthetic so that a tissue sample (biopsy) can be taken (see below).

A flexible cystoscopy usually takes 10–20 minutes. For a few days afterwards, you may experience some soreness, pain, or blood in your urine.

Rigid cystoscopy and biopsy

If earlier tests suggest that there are suspicious areas of tissue or tumours in your bladder, you will probably have a cystoscopy performed in hospital under a general anaesthetic. This type of cystoscopy uses a rigid cystoscope.

A biopsy is when tissue samples or small tumours are removed during the cystoscopy and sent to a pathologist to check for cancer cells. In the first few hours after the cystoscopy, you may have some difficulty controlling your bladder (incontinence), but this will usually settle. Continue to drink enough fluids and make sure you are near a toilet. You may have some soreness, pain, or blood in your urine for a few days.

If larger tumours need to be removed during a cystoscopy, the operation is called a transurethral resection of bladder tumour (TURBT).

"When I heard the word cancer, my mind just went completely blank. I was crying so hard I didn’t hear a word the doctor said after that. After a few days, I started to think more clearly again." - Ellen

Further tests

A CT or MRI can sometimes show how far the bladder cancer has spread, but you might also need further tests such as an FDG-PET scan, a radioisotope bone scan or x-rays. In some cases, cancer cells that have spread outside the bladder are not detected in further tests.

FDG-PET scan

FDG-PET (fluorodeoxyglucose positron emission tomography) is a specialised imaging test that can find disease in lymph nodes and at other sites that may not be picked up on a CT scan.

Before an FDG-PET scan, you will be injected with a specially modified sugar molecule (fluorodeoxyglucose or FDG). You will be sedated or asked to sit quietly for 30–90 minutes while the solution moves through your body. Cancer cells will absorb more of the FDG, so they will be highlighted when your body is scanned.

It will take several hours to prepare for the scan and to have it. You may want to take a book to read or bring a friend for company and support.

Radioisotope bone scan

A radioisotope scan may be done to see if any cancer cells have spread to the bones. This will usually only be done if the tumour is advanced or you have bone pain. It may also be called a whole body bone scan (WBBS) or simply a bone scan.

A tiny amount of radioactive dye is injected into a vein, usually in your arm. The dye collects in areas of abnormal bone growth. You will need to wait for several hours before having the scan. This gives the bones time to absorb the dye. The scanner will measure the radioactivity levels and record them on x-ray film.

You may want to bring a book or another activity to pass the time while you are waiting. Although only a little radioactive material is used, it may take a few hours to leave your body. You will need to drink plenty of fluids. The medical staff will discuss any precautions, such as avoiding contact with pregnant women and young children for the rest of the day. Speak to your doctor if you are concerned.

X-rays

You may need x-rays if a particular area looks abnormal in other tests or is causing symptoms. A chest x-ray may be taken to check the health of your lungs and for any signs the cancer has spread. This is sometimes done with the CT scanner.

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for any doctor to predict the exact course of your disease. Bladder cancer can usually be effectively treated, especially if it is found before it spreads outside the bladder.

To come up with your prognosis, your doctor will consider test results, the type of cancer you have, the rate and depth of tumour growth, how well you respond to treatment, and other factors such as your age, fitness and medical history.

Staging bladder cancer

To help plan treatment, tumours are given a stage to describe the extent of the cancer in the body. The most common staging system for bladder cancer is the TNM system (see below).

In this system, letters are assigned numbers to describe the cancer. Note that Ta, Tis and T1 are considered non-muscle-invasive bladder cancer, while T2, T3 and T4 are muscle- invasive bladder cancer (see diagram showing tumour locations below).

Another way of staging cancer is with numbers. There are usually four main stages: stage 1 is the earliest cancer and stage 4 is the most advanced. However, this method is not used often for bladder cancer. You can ask your doctor for more information.

Staging bladder cancer
TNM System
T (Tumour)

Indicates the size and depth of tumour invasion into the bladder and nearby tissues (see diagram above).

  • Ta – non-invasive papillary tumour (mushroom-like growth from the urothelium, or bladder lining)
  • Tis – carcinoma in situ (a flat tumour in the urothelium)
  • T1 – the tumour is in the lamina propria, the layer of tissue and blood vessels above the urothelium
  • T2 – the tumour is in the muscularis propria, the layers of muscle that surround the bladder
  • T3 – the tumour is in the layer of perivesical tissue (fat)
  • T4 – the tumour has invaded nearby structures, such as the prostate, uterus or pelvic wall
N (Nodes)

Shows if the cancer has spread to nearby lymph nodes.

  • N0 – the cancer has not spread to the lymph nodes
  • N1 – the cancer is in one lymph node in the pelvis
  • N2 – the cancer is in multiple lymph nodes in the pelvis
  • N3 – the cancer has spread to lymph nodes in the abdomen
M (Metastasis)

Shows if the cancer has spread to other parts of the body.

  • M0 – cancer has not spread to distant parts of the body
  • M1 – cancer has spread to distant parts of the body, such as the liver

Grading bladder cancer

Your doctor may talk to you about the grade of the cancer. This describes how quickly a cancer might grow. Knowing the grade helps your specialist predict how likely the cancer is to come back and if you need further treatment after surgery.

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

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

Carcinoma in situ (stage Tis in the TNM system) is a high-grade tumour that needs immediate, and sometimes aggressive, treatment to prevent it invading the muscle layer.

Key points

  • Several tests may be performed to diagnose bladder cancer. These include general tests, tests to find the position of the cancer, and tests to determine if the cancer has spread.
  • In an internal examination, the doctor will insert a gloved finger into your rectum or vagina to feel for anything unusual.
  • You may be asked to give blood or urine samples, which can show how your body is functioning and if infection or cancer cells are present.
  • In an ultrasound scan, the technician will spread gel over your abdomen and use a device called a transducer to create pictures of your organs.
  • CT and MRI scans involve an injection of dye into the body, followed by a scan.
  • Cystoscopy is the main test used to diagnose bladder cancer. A tube with a light and camera is inserted through the urethra to view the bladder.
  • A flexible cystoscopy can be done with local anaesthetic. If cancer is found, you will probably need to have a rigid cystoscopy under general anaesthetic in hospital. The doctor can take tissue samples (biopsy) and may be able to remove tumours.
  • Further tests, such as an FDG-PET scan, a radioisotope bone scan or x-rays, can show if the cancer has spread to other parts of the body.
  • The bladder cancer is assigned a stage to describe how much cancer there is and whether it has spread. The grade describes how fast the cancer is growing.

Reviewed by: A/Prof Manish Patel, Urological Cancer Surgeon, Westmead Private and Macquarie University Hospitals and University of Sydney, NSW; Gregory Bock, Urology Cancer Nurse Coordinator, WA Cancer and Palliative Care Network, Department of Health, WA; Leslie Leckie, Consumer; A/Prof Declan Murphy, Urologist, Chair of Uro-Oncology and Director of Robotic Surgery, Peter MacCallum Cancer Centre, VIC; Jan Priaulx, 13 11 20 Consultant, Cancer Council NSW.

Updated: 01 Feb, 2016