A look at how oncologists and pathologists determine bladder cancer staging and treatment.
The American Cancer Society estimates that more than 80,000 people will be diagnosed with bladder cancer in 2025. Staging, which designates how advanced a cancer is, helps determine the best course of treatment for patients.
“We can’t do that without a transurethral resection of the bladder tumor,” said Dr. Amy Luckenbaugh, a urologic oncologist with Vanderbilt Urology. The TURBT procedure, as it is commonly called, removes a tumor or growth (or part of it) by going through the urethra with a small tube called a scope. The procedure aids with diagnosis and staging.
A pathologist will then investigate the tumor. “From the pathology standpoint, we get a piece of tissue from a bladder and we look at it under a microscope,” said Dr. Jennifer Gordetsky, a urological pathologist in Vanderbilt’s departments of pathology and urology.
Understanding the layers of the bladder
“If you have blood in the urine, you shouldn’t assume it’s a urinary tract infection.”
Luckenbaugh said that explaining the bladder layers helps patients better understand staging.
Your bladder has four main layers, she said. The innermost layer is the urothelium. The next layer is a layer of nerves, blood vessels and connective tissue. Then comes a layer of muscle. Outside the muscle layer is a layer of fatty tissue separating your bladder from your other organs.
“Cancer can grow from where it begins down into the deeper tissues,” Gordetsky said. “It can keep growing and extend into surrounding organs, and it can metastasize, which means the cancer cells get into the bloodstream or to the lymphatics and then can travel to basically anywhere in the body — but commonly the liver, lungs and lymph nodes.”
How is bladder cancer staged?
Staging involves assigning the letters T, N and M. The letter “T” indicates if and how far the tumor has grown through the bladder wall and if it has grown into other tissues. An “N” indicates whether the cancer has spread to lymph nodes. And an “M” indicates whether the cancer has metastasized.
The letters T, N and M, are followed by additional letters, such as a lowercase “a” or “b” and the numbers 0 through 4. These designate other related factors.
For example, with a stage grouping of T1, N0, and M0, the “T1” indicates that the cancer has grown into the connective tissue layer but not the muscle layer or beyond. The “N0” indicates that the cancer has not spread to the nearby lymph nodes. The “M0” indicates that it has not metastasized.
As another example, a stage grouping of T2a, N0, M0 indicates that the cancer has started to grow into the muscle layer, but it has not passed through the muscle to the fatty layer, and it does not have lymph node involvement and has not metastasized. If this grouping included T2b, that would indicate that the cancer had grown farther into the muscle layer than a T2a designation.
Based on the stage grouping, your cancer will also be designated a Roman numeral I through IV. This staging designates how advanced the cancer is. In the example mentioned above of a T1, N0, M0 stage grouping, the cancer would likely be staged as stage I. However, the grouping of T2a, N0, M0 would likely be staged as stage II.
“You can have multiple tumors popping up in the bladder at the same time,” Dr. Gordetsky added. “So one tumor may not be invasive, but other tumors can be, so you can actually have different tumors in different parts of the bladder that are at a different stage.”
Staging can be complex and hard to understand. This chart from the American Cancer Society and a discussion with your doctor can help.
The importance of early diagnosis
As with most cancers, the earlier bladder cancer is diagnosed the better. That’s why both Gordetsky and Luckenbaugh emphasize the need to take unusual symptoms seriously. “The biggest thing,” Luckenbaugh said, “is if you have blood in the urine, you shouldn’t assume it’s a urinary tract infection.”
Seek a consultation with a doctor if you notice blood, urinary frequency or urgency, pain with urination, or difficulty emptying your bladder (voiding).
Personalized Care for Cancer
Vanderbilt Health’s Urological Cancers team is dedicated to preventing, diagnosing and treating cancers that affect the kidney, bladder, prostate and testicles. The specialized team works together to provide a precise diagnosis and effective treatment options.
