Diagnosing bladder cancer

 


To diagnose bladder cancer, your general practitioner (GP) may examine you and then refer you to a specialist. The tests you have will depend on your specific situation and may include:

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

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

General 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 also be asked to give a urine sample, which will be checked for blood and bacteria – this test is called a urinalysis. If you have blood in your urine, you may be asked to give three separate urine samples over three days, which will be sent to a laboratory to look for cancer cells – this test is called a urine cytology.

Tests to find cancer in the bladder

To determine the position and extent 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 additional tests.

Your medical team will usually ask you to have a full bladder for the ultrasound. After the first scan, you will 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 cool 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.

Cystoscopy

A cystoscopy is a common procedure for diagnosing bladder cancer. A thin tube with a light and a camera on the end (cystoscope) is used to examine the inner lining of the bladder. The cystoscope may be flexible or rigid.

Flexible cystoscopy

In many cases, your first cystoscopy will be done under local anaesthetic using a flexible cystoscope. 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.

This procedure usually takes 10–20 minutes. For a few days afterwards, you may see blood in your urine and feel mild discomfort when passing 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 with a rigid cystoscope. It will be performed in hospital under a general anaesthetic.

With this type of cystoscope, a biopsy can be taken. This 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 rigid cystoscopy, you may have some difficulty controlling your bladder (incontinence), but this will usually settle. Continue to drink fluids and make sure you are near a toilet. You may also have some discomfort, need to pass urine urgently or have blood in your urine for a few days. Avoid lifting anything heavy until the bleeding has settled.

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

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 urothelial carcinoma, 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 a vein to make the pictures clearer. 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 that moves in and out of the 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 can cause allergies in some people. If you've had a reaction to dyes during a previous scan, tell your medical team beforehand. You should also let them know if you are diabetic, have kidney disease or may be pregnant.

MRI scan

Less commonly, an MRI (magnetic resonance imaging) scan may be used to check for bladder cancer. This scan uses a powerful magnet to build up cross-sectional pictures of organs in your abdomen. Before the scan, let your medical team know if you have a pacemaker, as the magnetic waves can interfere with some types of 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. You will hear loud repetitive sounds. The radiographer will place you in a position that will enable you to stay still so that movement is limited during the MRI.

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 earplugs or headphones to listen to music.

The MRI scan takes between 30 and 90 minutes.

Further tests

A CT or MRI scan can sometimes show how far the bladder cancer has spread, but you might also need further imaging tests such as a radioisotope bone scan, x-rays or an FDG-PET scan.

Radioisotope bone scan

A radioisotope scan may be done to see whether the cancer has spread to the bones. 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 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.

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.

FDG-PET scan

This scan can be used to find cancer that has spread to lymph nodes or other sites that may not be picked up on a CT scan. Medicare does not currently cover the cost of an FDG-PET (fluorodeoxyglucose-positron emission tomography) scan for bladder cancer. If this test is recommended, check with your doctor what you will have to pay. PET scans are usually found only in major hospitals, so you may need to travel to have one.

Before an FDG-PET scan, a small amount of radioactive solution is injected into a vein. This specially modified sugar molecule is called fluorodeoxyglucose or FDG. You will be sedated or asked to sit quietly for 30–90 minutes while the solution moves through your body. Your body is then scanned. Areas of cancer usually absorb more of the FDG, so they will be highlighted on the scan. It will take several hours to prepare for and have the scan.

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 the disease. Bladder cancer can usually be effectively treated, especially if it is found before it spreads outside the bladder.

To work out your prognosis, your doctor will consider test results, the type of bladder 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.

TNM system

T (Tumour)
Describes how far the tumour has grown into the wall of the bladder and nearby tissues Ta – non-invasive papillary tumour (finger-like growth from the urothelium or bladder lining) Tis – carcinoma in situ (flat tumour in the urothelium) T1 – tumour is in the lamina propria (layer of tissue and blood vessels surrounding the urothelium)
T2 – tumour is in the muscularis propria (muscular layer surrounding the bladder) T3 – tumour is in the layer of perivesical tissue (fat) T4 – tumour has spread beyond bladder, e.g. to prostate, uterus, vagina 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 has spread to one lymph node in the pelvis
N2 – the cancer has spread to 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 others 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

In this system, letters are assigned numbers to describe the cancer – Ta, Tis and T1 are considered non-muscle-invasive bladder cancer, while T2, T3 and T4 are muscle-invasive bladder cancer.

Another way of staging cancer is with numbers. There are 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.

Grading bladder cancer

The biopsy results will also tell your doctor 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 (recur) 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 both into the bladder muscle and outside the bladder.

In non-muscle-invasive tumours, 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 high-grade tumour that needs immediate, and sometimes aggressive, treatment to prevent it invading the muscle layer.

Which health professionals will I see?

Your GP will usually arrange the first tests to assess your symptoms. If these tests don't rule out cancer, you'll be referred to a urologist or to a local hospital that specialises in urology. The urologist will examine you and may do more tests. A range of health professionals will work as a multidisciplinary team (MDT) to treat you.

The following health professionals may be in your MDT. Note that only some patients see a cancer care coordinator. If the bladder cancer is non-muscle-invasive, you are unlikely to need systemic chemotherapy or radiation therapy, so you probably won't have to see a medical oncologist or radiation oncologist.

MDT health professionals
GP works in partnership with your specialists in providing ongoing care
urologist* specialises in diseases of the male and female urinary systems and the male reproductive system; performs surgery
medical oncologist* prescribes and coordinates the course of chemotherapy
radiation oncologist* prescribes and coordinates the course of radiation therapy
cancer care coordinator or clinical nurse consultant support patients and families throughout treatment and liaise with other members of the treatment team
nurses care for you during and after surgery; administer drugs, including chemotherapy; and provide care, information and support throughout treatment
stomal therapy nurse provides advice and support to patients with a stoma
continence nurse assesses and educates patients about bladder and bowel control
dietitian recommends an eating plan to follow during treatment and recovery
social worker links you to support services and helps you with emotional or practical issues
clinical psychiatrist*, psychologist, counsellor provide emotional support and help manage any feelings of depression and anxiety
physiotherapist, occupational therapist help with physical and practical problems, including restoring a range of movement after surgery

* Specialist doctor

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.
  • 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 small tumours.
  • CT and MRI scans involve an injection of dye into the body, followed by a scan.
  • Further tests, such as a radioisotope bone scan, x-rays or an FDG-PET scan, can show if the cancer has spread to other parts of the body.
  • 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.

Expert content reviewers:

Phil Dundee, Urological Surgeon, Epworth Hospital, VIC; David Connah, Consumer; Dr Elizabeth Hovey, Senior Staff Specialist, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, and Conjoint Senior Lecturer, University of New South Wales, NSW; Colleen McDonald, Clinical Nurse Consultant Urology, Westmead Hospital, NSW; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council Western Australia, WA; Kerry Santoro, Urology Nurse Consultant, Repatriation General Hospital, SA.

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