Bladder cancer

Overview

•4th most common cancer in men in the UK; ~10,000 new cases/year

•Male:female ratio ~3:1; peak incidence 60-80 years

•>90% are urothelial carcinomas (formerly transitional cell carcinoma)

•75-80% present as non-muscle-invasive bladder cancer (NMIBC)

Risk Factors

Classification

NMIBC vs MIBC

Feature	NMIBC (Ta, T1, Tis)	MIBC (T2-T4)
Definition	Has NOT invaded muscularis propria	Has invaded muscularis propria
Proportion	75-80% of cases	20-25% of cases
5-year survival	80-90%	30-60%
Recurrence	Very high - 70-80% within 5 years	N/A - definitive treatment required

⚠️

Carcinoma in situ (CIS/Tis) is a flat, high-grade lesion that does NOT invade but has a high propensity to progress to MIBC - treat aggressively despite superficial appearance.

Presentation

•Painless visible haematuria - cardinal symptom; present in up to 85% of cases; ANY single episode warrants urgent investigation

•Non-visible (microscopic) haematuria - detected on dipstick; still warrants investigation in older patients

•Irritative LUTS (frequency, urgency, dysuria) - suggests CIS causing diffuse mucosal inflammation

•Recurrent UTI in an older patient - tumour as nidus for infection; investigate further

•Loin pain / hydronephrosis - ureteric obstruction; late/locally advanced sign

🎯

Haematuria in women is more often attributed to UTI, delaying diagnosis. If haematuria does not resolve after antibiotics or recurs, investigate for malignancy regardless of sex.

Investigations

🥇 First-line

•urine dipstick and microscopy - confirm haematuria, exclude UTI (send MSU for culture)

•urine cytology - high specificity for high-grade disease; low sensitivity for low-grade tumours

•renal tract ultrasound - initial imaging; identifies bladder mass or upper tract pathology

🏆 Gold standard

•flexible cystoscopy with biopsy (TURBT specimen) - direct visualisation and histological confirmation of tumour type and depth of invasion

🥈 Second-line

•CT urogram - staging; assesses upper tract, lymph nodes, distant metastases, ureteric obstruction

•MRI pelvis - depth of bladder wall invasion (T-staging) or radiotherapy planning

📌

NICE NG12 two-week wait referral: adults ≥45 with unexplained visible haematuria without UTI, OR visible haematuria persisting after UTI treatment. Adults ≥60 with unexplained non-visible haematuria plus dysuria or raised WCC also warrant urgent referral.

Management

Step 1 · All bladder cancer

1. 1TURBT (transurethral resection of bladder tumour) - diagnostic and therapeutic; establishes T-stage and grade

↓

NMIBC (Ta, T1, Tis)

Single instillation of mitomycin C intravesically within 24 h of TURBT (low/intermediate risk). High-risk NMIBC (T1, high-grade, CIS, multifocal): intravesical BCG - stimulates local Th1 immune response to destroy residual tumour cells and reduce progression risk. Surveillance cystoscopy programme.

MIBC (T2-T4)

Radical cystectomy (ileal conduit or orthotopic neobladder) OR radical radiotherapy with radiosensitising chemotherapy. Neoadjuvant platinum-based chemotherapy considered before radical cystectomy.

↓

Step 3 · Metastatic disease

1. 1Systemic chemotherapy (platinum-based); 5-year survival ~10-15%

Complications

•Tumour recurrence - 70-80% of NMIBC within 5 years; requires lifelong surveillance

•Progression to MIBC - especially high-grade, multifocal, or CIS-associated NMIBC (~10-15%)

•Upper urinary tract tumours - urothelial carcinoma can arise in renal pelvis or ureter (field defect)

•BCG sepsis - rare but serious systemic infection; requires anti-tuberculous therapy

•Post-cystectomy - erectile dysfunction (S2/3/4 nerve damage), urinary incontinence, metabolic acidosis, vitamin B12/folate deficiency (ileal conduit interrupts ileal absorption)

Prognosis

•NMIBC (Ta, T1): 5-year survival 80-90%; recurrence 70-80% within 5 years; ~10-15% progress to MIBC

•MIBC (T2-T4): 5-year survival 30-60% depending on invasion depth and nodal status

•Metastatic disease: 5-year survival ~10-15%

•Key prognostic factors: tumour grade, T-stage, and presence of CIS; recurrence within 3-6 months of TURBT indicates aggressive phenotype