Urinary Bladder (Urothelial) Cancer

Bladder Cancer: A Complete Guide for Patients and Caregivers

Understanding bladder cancer can feel overwhelming. This guide explains the condition in clear, simple language — including symptoms, diagnosis, staging, and treatment options — so patients and families can make informed decisions confidently.

What Is the Bladder?

The bladder is a hollow muscular organ that stores urine and releases it when you urinate. It expands as it fills and contracts when emptying.

What Is Bladder Cancer?

Bladder cancer develops when abnormal cells in the bladder lining begin to grow uncontrollably. The most common type is urothelial carcinoma, though other types such as squamous cell carcinoma and adenocarcinoma can occur.

If left untreated, bladder cancer may grow deeper into the bladder wall or spread to other parts of the body.

Causes and Risk Factors

Risk factors include:

• Smoking (the strongest risk factor)
• Exposure to industrial chemicals (dyes, rubber, leather, fuel industries)
• Chronic bladder inflammation or infections
• Long-term catheter use
• Previous radiation or certain chemotherapy drugs
• Age over 55 and male gender

Genetic Factors

Most bladder cancers are not inherited, but tumour-level genetic changes may influence treatment.

Signs and Symptoms

Common symptoms include:

• Blood in urine (even once)
• Frequent urination
• Pain or burning during urination
• Difficulty urinating or weak stream
• Pelvic or lower back pain

Blood in urine should always be evaluated.

Diagnosis

Diagnosis usually involves:

Urine Testing

• Urine cytology to look for cancer cells
• Special urine marker tests where appropriate

Imaging

• Ultrasound
• CT or MRI urogram
• PET-CT in selected cases

Cystoscopy and TURBT

A camera is inserted into the bladder to examine the lining. If an abnormality is seen, a procedure called TURBT (Transurethral Resection of Bladder Tumour) is performed to remove and sample the tumour.

Molecular Testing

Tumour samples may be tested for genetic markers such as FGFR or HER2, especially in advanced disease.

Staging

Treatment Options

Treatment depends on the stage and patient suitability.

Non-Muscle-Invasive Bladder Cancer (Stage 0–1)

Treatment may include:

• TURBT
• Intravesical therapy such as:
  • BCG immunotherapy
  • Intravesical chemotherapy

Regular cystoscopy follow-up is essential because recurrence is common.

Muscle-Invasive Bladder Cancer (Stage 2–3)

Treatment may include:

• Radical cystectomy (bladder removal surgery)
• Bladder-preserving chemoradiation in select cases
• Reconstruction options such as neobladder, urostomy, or continent diversion

Neoadjuvant Therapy (Before Surgery)

For muscle-invasive disease, treatment before surgery may be recommended to improve long-term outcomes. This is called neoadjuvant therapy and may involve:

• Chemotherapy
• Immunotherapy
• or a combination of both

Cisplatin-based chemotherapy is most commonly used and can help shrink the tumour and reduce the risk of recurrence. Immunotherapy may be considered for selected patients. After neoadjuvant treatment, most patients proceed to surgery or bladder-preserving therapy.

Metastatic Bladder Cancer (Stage 4)

When bladder cancer spreads beyond the bladder, treatment focuses on controlling cancer, reducing symptoms, and maintaining quality of life. Systemic therapy (whole-body treatment) is the main approach.

First-Line Treatment

Many patients receive a combination of:

• Enfortumab Vedotin (an ADC)
• Pembrolizumab (immunotherapy)

This combination has shown improved outcomes compared with chemotherapy alone in many individuals.

If this combination is not suitable, alternatives may include:

• Platinum-based chemotherapy
• Chemotherapy plus immunotherapy
• ddMVAC in suitable patients

Maintenance Therapy

If platinum-based chemotherapy was used first and the cancer is stable or responding, ongoing immunotherapy may be offered to help maintain control.

Second-Line and Later Treatment Options

If cancer grows after initial treatment, options may include:

• Immunotherapy (Pembrolizumab, Nivolumab, Avelumab)
• Antibody-drug conjugates alone or in combination
• Chemotherapy again, depending on prior treatment
• Targeted therapy based on tumour genetics (FGFR or HER2-directed treatments)

What Are Antibody-Drug Conjugates (ADCs)?

ADCs are a newer treatment designed to deliver powerful anti-cancer medicine directly to tumour cells while protecting healthy tissue.

They work by:

• Targeting a protein on the cancer cell
• Attaching to it like a key fitting a lock
• Delivering the chemotherapy payload inside the tumour cell

This makes treatment more precise and potentially more effective.

Supportive and Symptom Management

Pain control, emotional support, nutrition, and mobility support can improve comfort and wellbeing throughout treatment.

Living with Bladder Cancer

Living with bladder cancer may include:

• Avoiding smoking
• Attending regular follow-up appointments
• Maintaining good nutrition and activity levels where possible
• Seeking emotional and psychological support

Support groups, counselling, and rehabilitation specialists may play valuable roles.

Key Points to Remember

• Bladder cancer is treatable and treatment options are evolving.
• Blood in urine should never be ignored.
• Treatment depends on stage and may include surgery, chemotherapy, immunotherapy, targeted therapy, or antibody-drug conjugates.
• Advances in modern therapy are improving outcomes, especially for advanced disease.
• Patients and caregivers are supported throughout the treatment journey.