Bladder cancer signs of progression its most dangerous types and its treatment

Bladder cancer is one of the serious diseases that affect the urinary system, and it represents a major challenge for patients and their families. Knowing the warning signs of deterioration and understanding the most dangerous types is an important step for early detection and improving treatment outcomes.In this article by Dalili Medical, you will learn about the symptoms you need to pay attention to, the most aggressive types of bladder cancer, and the latest treatment options – including surgery, chemotherapy, radiotherapy, immunotherapy, and targeted therapy.Reading this article will give you a comprehensive and clear overview of the disease and the best ways to deal with it.

What is bladder cancer?

Bladder cancer is a type of cancer that begins in the lining of the bladder, which is a small hollow organ that stores urine before it leaves the body. It can be treated in several ways, mainly surgery, but regular follow-up is very important because the cancer can return after treatment — especially in early-stage cases, as studies show that about 75% of early bladder cancers may recur.

How does bladder cancer affect my body?

The bladder is a triangular-shaped organ located between the hip bones, above the urethra and below the kidneys. Urine flows from the kidneys to the bladder, which is lined with special cells called urothelial cells. These cells stretch when the bladder fills and contract when it empties. A healthy bladder can normally store about two cups of urine.

When bladder cancer develops, some of these cells transform into abnormal cells that multiply rapidly and form tumors. If left untreated, cancer can spread through the bladder wall to nearby lymph nodes, and then to other organs such as the bones, lungs, and liver.

Which are more common: benign or malignant bladder tumors?

Malignant (cancerous) tumors: represent the vast majority of bladder tumors.
Benign tumors: are rare and account for only about 1–5% of cases.

Is bladder cancer fast-spreading?

Bladder cancer has two main categories:

Non-muscle invasive bladder cancer (NMIBC):

Usually slow-growing
Remains limited to the inner lining of the bladder
Rarely spreads to other organs

Muscle-invasive bladder cancer (MIBC):

Grows into deeper layers of the bladder wall
Can spread more quickly to nearby organs
Requires urgent treatment and close follow-up

Can bladder cancer come back after removal?

Yes. Bladder cancer may return even after the bladder is removed. Studies show the recurrence rate ranges from 1% to 8%.
This is why regular screening and follow-up with your doctor are crucial for early detection of any recurrence.

How is urination done after bladder removal?

After removing the bladder, an alternative pathway for urine must be created. There are different methods:

External bag (Ileal Conduit): urine drains into a bag worn outside the body.
Neobladder: made from a piece of the intestine to allow urination in a more natural way through the urethra.

Where does bladder cancer spread?

Bladder cancer initially affects the inner layers, then gradually spreads to nearby and distant areas.

Common sites of metastasis include:

pelvic and abdominal lymph nodes
liver
lungs
bones

Does bladder cancer cause infertility?

Bladder cancer itself usually does not cause infertility.
However, some treatments — such as surgery or radiation — may affect reproductive organs and reduce fertility, especially in men.
So it is important to discuss fertility-preservation options with the doctor before starting treatment.

How common is bladder cancer?

Bladder cancer is the fourth most common cancer among men.
Men are four times more likely to develop it than women.
Women are often diagnosed at later stages because they may ignore an early and important sign — blood in the urine — and relate it to minor gynecological issues.
The most common age at diagnosis is 55 years and older, with the average at about 73 years.
White men are twice as likely as Black men to develop bladder cancer.

Is bladder cancer fatal?

If bladder cancer is left untreated, it can spread to other parts of the body, which lowers survival rates.

Early detection and proper treatment significantly increase the chances of long-term survival.

According to the National Cancer Institute:

96% of people diagnosed and treated early survive 5 years after diagnosis.
Overall, about 77% of all patients survive 5 years after diagnosis.

Is a urine test enough to detect bladder cancer?

A urine test alone is usually not enough to diagnose bladder cancer definitively.
If any abnormal findings appear in the test, doctors move on to more accurate diagnostic tools, including:

Cystoscopy:

The most accurate test for diagnosing bladder cancer
Allows direct visual inspection of the bladder lining
Also used to treat superficial (non-invasive) tumors

Imaging tests

These include CT scans and MRI to monitor the size of the tumor and whether it has spread.

Biopsy

A sample of bladder tissue is taken and examined under the microscope to confirm the diagnosis.

What causes bladder cancer?

Doctors do not know one fixed 100% definite cause, but there are several factors that increase the risk:

Smoking

The most common cause — linked to more than half of bladder cancer cases.

The toxic substances in cigarettes enter the bloodstream, then are filtered by the kidneys and stay in the bladder for some time, which can lead to changes in bladder cells.

Exposure to industrial chemicals

Especially in workers in:
printing houses, rubber factories, textile dyeing, petroleum and its derivatives, and aluminum industries.

These chemicals enter the blood, then the urine — increasing cancer risk.

Chronic bladder inflammation

Repeated bladder infections for long periods, or long-term urinary catheter use, may change bladder cell structure and increase the risk of cancer.

Previous radiation to the pelvic area

People who received radiation therapy to treat pelvic tumors (such as uterine cancer) have a higher risk of developing bladder cancer years later.

Certain chemotherapy drugs

Such as cyclophosphamide, used for treating some cancers — it increases the chance of bladder cancer later.

Genetics and family history

Having a close family member with bladder cancer increases the risk, but this is less common than smoking.

Parasitic infections in certain regions

Such as schistosomiasis, which is common in some rural areas, and is a known cause of a specific type of bladder cancer.

Types of bladder cancer

1) Transitional Cell Carcinoma (TCC)

Most common type — about 90% of cases.

Starts in transitional cells lining the bladder that stretch and contract with urine.

Two forms exist within this type:

Type	Description
Papillary	Forms thin finger-like projections inside the bladder
Flat carcinoma	Grows flat on the bladder lining without projections

2) Squamous Cell Carcinoma

About 5% of cases.
More common in people who have chronic bladder irritation or long-term catheters.
Common in countries where schistosomiasis is widespread.

3) Adenocarcinoma

Very rare — around 1% of cases.
Starts from glandular cells in the bladder.
Sometimes occurs in people with long-standing inflammation.

4) Small Cell Carcinoma

Very rare and very fast-growing.
Spreads quickly.
Looks similar to a type of lung cancer under the microscope.

5) Mixed Tumors

In some cases, the tumor contains more than one cell type at the same time.

Important note: Most bladder cancer cases are TCC. Early detection is very important because the tumor may return after treatment — so regular follow-up is essential.

Symptoms of bladder cancer

Blood in the urine (Hematuria)

Most common symptom.
The urine may look red, pink, or brown.
Sometimes blood is invisible and only detected in urine tests.
Blood may appear, disappear, then return again.

Pain or burning during urination

Burning sensation or pain lower in the abdomen when urinating.

Frequent urination

Feeling the need to urinate often, even with small amounts of urine.

Urgency to urinate

Sudden, strong urge to urinate that is hard to delay.

Pain in the pelvis or lower back

Often appears in advanced stages when the tumor starts affecting nearby tissues.

Symptoms when bladder cancer spreads outside the bladder

Site of spread	Possible symptoms
Bones	Severe bone pain, easy fractures
Lungs	Persistent cough, shortness of breath
Liver	Abdominal pain, sometimes yellowing of the skin

Stages of bladder cancer

1. TNM Classification System

The stage depends on 3 key factors:

T (Tumor): how deep the tumor has grown into the bladder wall
N (Nodes): whether lymph nodes are involved
M (Metastasis): whether there is spread to distant organs

2. T categories (extent of tumor)

Category	Description
Tis	carcinoma in situ — flat, high-grade, non-invasive
Ta	papillary tumor, non-invasive
T1	tumor reached connective tissue but not muscle
T2	tumor invaded bladder muscle (muscle invasive)
T2a	outer half of muscle
T2b	deeper half of muscle
T3	tumor penetrated muscle into fat around bladder
T3a	microscopic spread
T3b	visible macroscopic spread
T4	spread to nearby organs or pelvic/abdominal wall
T4a	prostate (men), uterus/vagina (women)
T4b	pelvic or abdominal wall

3. N and M categories (lymph nodes & metastasis)

Category	Description
N0	no lymph nodes involved
N1	one lymph node involved
N2/N3	multiple or larger lymph nodes, or distant nodes
M0	no distant spread
M1	distant spread
M1a	distant lymph nodes
M1b	distant organs such as lung, liver, bone

4. Stage grouping (Stage 0 → IV)

Stage	Description
Stage 0a	superficial non-invasive tumors, usually treated with TURBT + surveillance
Stage 0is	carcinoma in situ — high-risk, needs strong intravesical therapy
Stage I	tumor in connective tissue under lining, treated with TURBT ± BCG
Stage II	muscle-invasive — usually needs radical surgery or chemoradiation
Stage IIIA/IIIB	spread to surrounding tissues & regional lymph nodes
Stage IVA/IVB	distant spread — treatment focuses on control (chemo, immunotherapy)

Are the symptoms of benign bladder tumors different from cancer?

Similarities

Whether benign or malignant, the most common symptom is blood in urine.
Also possible:

urinary frequency
burning with urination
lower abdominal pain

So symptoms alone cannot differentiate.

Key difference

Bladder cancer:

stronger symptoms over time
complications may include recurring bleeding, pelvic pain, unexplained weight loss (advanced cases)

Benign tumors:

milder symptoms
do not spread
do not usually cause weight loss or constant pain

But they still may cause blood in urine — so symptoms alone are not enough for diagnosis.

Diagnosis and tests for bladder cancer

Diagnosis is based on a combination of tests, starting with symptoms and followed by more specific investigations:

Urine test to detect blood (even if not visible) and sometimes abnormal cells
Urine cytology to look for cancer cells under the microscope — especially useful for high-grade tumors
Cystoscopy — most important diagnostic tool, uses a thin camera through the urethra to see the bladder lining directly
Biopsy — taken during cystoscopy to confirm cancer and grade it
CT / MRI scans — to assess tumor spread inside or outside the bladder & evaluate lymph nodes
CT urography / IVU — to evaluate kidneys and ureters if spread outside the bladder is suspected

When should you see a doctor?

If you notice any of the following signs, you should consult a specialist immediately:

Blood in the urine (even once)
Persistent pain or burning during urination without a clear cause
Noticeably frequent urination

Blood in the urine is the most important early sign of bladder cancer — do not ignore it.

How can bladder cancer be prevented?

It may be difficult to completely prevent bladder cancer, but knowing the risk factors can help reduce the chance of developing it:

Cigarette smoking

Smoking increases the risk of bladder cancer by more than double.
This includes cigarettes, pipes, cigars, and secondhand smoke.

Previous cancer treatments

Radiation therapy increases the risk.
Some chemotherapy drugs can also increase the risk of bladder cancer later in life.

Exposure to chemicals

People working with aromatic amines (used in dyes), rubber, leather, textiles, paints, and certain hairdressing products are at higher risk.

Chronic bladder infections

Repeated bladder infections, bladder stones, or urinary tract problems can increase the risk.

Previous bladder cancer

Individuals who had bladder cancer before are more likely to develop new tumors or recurrence.

Knowing these factors helps you reduce risks through lifestyle changes and regular medical follow-up.

Treatments for bladder cancer

1. Transurethral Resection of Bladder Tumor (TURBT)

Procedure:
A thin scope is inserted through the urethra to reach the bladder, and the tumor is removed without abdominal incision.

When is it used?
For small and superficial (non-muscle-invasive) cancers.

Advantages:

Less pain
Short recovery period
No abdominal surgery

Limitations:
The tumor may return, so follow-up or intravesical chemo/immunotherapy is often required.

2. Partial Cystectomy

Procedure:
Removal of the part of the bladder that contains the tumor, along with a safe margin of normal tissue.

When is it used?
If the tumor is localized in one region of the bladder and cannot be treated with TURBT.

Advantages:
Preserves part of the bladder → better urinary function.

Limitations:
Not suitable for all cases, and close monitoring is needed because recurrence is possible.

Chemotherapy for bladder cancer

When is chemotherapy used?

Before surgery (neoadjuvant):
To shrink the tumor before removing the bladder.

After surgery (adjuvant):
To reduce the risk of recurrence.

For invasive or advanced cancer:
If cancer has spread to lymph nodes or distant organs.

Intravesical chemotherapy:
Delivered directly into the bladder for superficial tumors to prevent recurrence.

Methods of giving chemotherapy

A. Systemic chemotherapy (IV infusion)

Given through a vein to reach all parts of the body.

Common regimens:

GC: Gemcitabine + Cisplatin
MVAC: Methotrexate + Vinblastine + Adriamycin + Cisplatin

Duration:
Usually 3–6 cycles, each cycle 2–4 weeks depending on the protocol.

B. Intravesical chemotherapy

Drug is placed directly into the bladder through a catheter.

Common drugs: Mitomycin C and BCG (also a form of intravesical immunotherapy).

Goal:
Kill superficial cancer cells and prevent recurrence.

Duration:
Weekly for 6–8 weeks, then maintenance doses as needed.

Radiation therapy for bladder cancer

When is radiation used?

As a primary treatment:
For patients who cannot undergo surgery because of health issues or age.

After surgery:
To reduce the chance of recurrence, especially if risk of spread is high.

For advanced/metastatic cancer:
To relieve symptoms such as pain or bleeding (palliative care).

Types of radiation therapy

A. External Beam Radiation Therapy (EBRT)

A beam of high-energy radiation is directed at the bladder from outside the body.

Schedule:
Daily sessions, 5 days per week for 4–7 weeks depending on tumor size and stage.

Goal: kill cancer cells while preserving as much healthy tissue as possible.

B. Brachytherapy (internal radiation) – less common

A radioactive source is placed inside or very close to the bladder tumor.

Goal: deliver concentrated radiation directly to the tumor with less harm to surrounding tissue.

Immunotherapy for bladder cancer

A. Intravesical immunotherapy

Most common: BCG (Bacillus Calmette-Guérin)

Method: drug placed directly in the bladder through a catheter and left for about 2 hours.

Goal: stimulate the immune system to attack surface cancer cells and prevent recurrence.

Schedule: weekly for 6 weeks, then maintenance doses as needed.

B. Systemic immunotherapy

Used for invasive or metastatic cancer that is not operable or resistant to chemotherapy.

Examples: immune checkpoint inhibitors such as Pembrolizumab and Atezolizumab.

Goal: help the immune system attack cancer cells.

Administration: IV infusion every few weeks depending on protocol.

Targeted therapy for bladder cancer

What is targeted therapy?

Drugs that target specific molecules or genetic mutations in cancer cells — with less impact on normal cells.

Goal: precise attack on cancer with fewer side effects.

Main types

Tyrosine kinase inhibitors (TKIs): block growth signals inside cancer cells.
Monoclonal antibodies: bind to receptors on cancer cell surfaces to block growth or help the immune system attack.
Example: Erdafitinib for bladder cancers with FGFR mutation.
Antibody-drug conjugates: combine a monoclonal antibody with a toxic agent and deliver it directly to cancer cells.
Example: Enfortumab vedotin for advanced or chemo-resistant cases.