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The information on this page was reviewed and approved by
Maurie Markman, MD, President, Medicine & Science at CTCA.

This page was updated on July 22, 2021.

Bladder cancer staging

Doctors take into account many factors when determining the stage of bladder cancer, including how it’s growing in the bladder, where it’s growing in the bladder and where it’s spread, both inside and outside the bladder. They may also consider what the cancer cells look like under a microscope.

Results from physical exams, biopsies and imaging tests are all used as pieces in the puzzle to determine the cancer’s stage. To diagnose bladder cancer, doctors likely performed a biopsy surgery called a transurethral resection of bladder tumor, or TURBT, in which a tissue sample is examined. Staging after surgery is called the pathologic stage, and it’s typically more accurate than staging that only uses the tests before surgery, called clinical staging.

Noninvasive vs. invasive

Doctors often use the terms “noninvasive” or “invasive” to describe whether cancer has spread into the bladder wall. Noninvasive means the cancer is in the inner cell layers. Invasive cancers are deeper in the layers of the bladder wall. If a doctor says the cancer is superficial or non-muscle invasive, that means it isn’t in the bladder’s main muscle layer—though it may still be invasive or noninvasive and have the potential to spread to the muscle.

Different types of bladder cancer grow in different ways, so doctors may discuss a tumor in terms of the direction it’s growing. Papillary carcinomas grow from the bladder’s lining toward the hollow center, while flat carcinomas stay flush against the bladder wall.

TNM staging system

The most common way doctors describe bladder cancer stages is using the American Joint Committee on Cancer (AJCC) TNM system. This system uses three letters, each of which is assigned a different number. Each letter stands for a specific characteristic of the cancer.

  • T is for tumor: How big the primary tumor (the tumor in the bladder) is and where it’s situated in the bladder
  • N is for nodes: Whether the cancer has spread to nearby lymph nodes and, if so, how many it has spread to
  • M is for metastasis: Whether the cancer has spread, or metastasized, to other parts of the body, such as the lungs, liver or lymph nodes far from the bladder

After each letter, there’s a number, a lowercase letter, or both, which provide even more specific details about the cancer. The higher the number, the more advanced the cancer.

T categories for bladder cancer:

  • TX means the primary tumor cannot be assessed or information isn’t known.
  • T0 means there’s no evidence of a primary tumor.
  • Ta indicates noninvasive papillary carcinoma.
  • Tis indicates noninvasive flat carcinoma, also called flat carcinoma in situ. This means that the disease is still localized, or contained within the urothelium layer of the bladder wall. Cancer cells haven’t invaded the deeper layers of bladder wall tissue.
  • T1 means the tumor has grown from the layer of cells lining the bladder into the connective tissue below. It hasn’t grown into the muscle layer of the bladder. T2 means the tumor has grown into the muscle layer.
  • T2 has two subcategories:
    • T2a indicates the tumor is in the inner half of the muscle layer.
    • T2b indicates the tumor is in the outer half of the muscle layer.
  • T3 means the tumor has grown through the muscle layer and into the surrounding fatty tissue. T3 has two subcategories:
    • T3a indicates that this spread into the fatty tissue may be seen only with a microscope.
    • T3b indicates that this spread into the fatty tissue is large enough to be seen on an imaging test or to be seen/felt by a surgeon.
  • T4 means the tumor has spread into nearby organs or structures and may be growing in the stroma (main tissue) of the prostate, the seminal vesicles, uterus, vagina, pelvic wall or abdominal wall.

N categories for bladder cancer:

  • NX means nearby lymph nodes cannot be assessed or information isn’t known.
  • N0 means the cancer has not spread to nearby lymph nodes.
  • N1 means the cancer has spread to one lymph node in the pelvis.
  • N2 means the cancer has spread to two or more lymph nodes in the pelvis.
  • N3 means the cancer has spread to lymph nodes that lie along the common iliac artery.

M categories for bladder cavity and oropharyngeal cancers:

  • M0 means no distant spread
  • M1 means the cancer has spread to distant sites outside the bladder region (for example, the lungs, liver or bones)

Bladder cancer stages

Doctors assess all of the information from the TNM characteristics and then assign an overall stage of 0 through 4. These numbers generally indicate how much the cancer has spread. Some stages have substages, too, indicated by letters after the number.

Below are descriptions for each stage, along with the corresponding TNM characteristics.

Stage 0

  • Stage 0a (noninvasive papillary carcinoma): Cancer grows toward the center of the bladder, but it hasn’t grown into the connective tissue of the bladder wall or muscle and hasn’t spread outside the bladder.
    • The TNM characteristics are Ta, N0, M0.
  • Stage 0is (flat carcinoma in situ): Cancer grows flat against the bladder’s tissue lining, but it hasn’t spread to the bladder wall’s muscle or connective tissue and hasn’t spread outside the bladder.
    • The TNM characteristics are Tis, N0, M0.

Stage 1

  • Stage 1 bladder cancer doesn’t have substages. In stage 1, the cancer is growing into the connective tissue in the bladder wall, called the lamina propria, but hasn’t reached the muscle and hasn’t spread outside the bladder.
  • The TNM characteristics are T1, N0, M0—since the tumor has grown into connective tissue but isn’t affecting lymph nodes and hasn’t spread anywhere else.

Stage 2

  • The cancer has grown into the muscle layer but hasn’t reached surrounding fatty tissue. It hasn’t spread to lymph nodes or distant sites.
    • The TNM characteristics are T2 (a or b), N0, M0.

Stage 3

  • Stage 3A: Cancer has spread to the fat layer around the bladder (the perivesical tissue) and may have spread to reproductive organs, or cancer has spread to a lymph node in the pelvis that isn’t close to the major pelvic arteries.
    • The TNM characteristics are T3a or T3b or T4a, N0, M0 or T1-4a, N1, M0.
  • Stage 3B: Cancer has spread to multiple lymph nodes in the pelvis that aren’t close to the major pelvic arteries or to one or more lymph nodes near the major pelvic arteries.
    • The TNM characteristics are T1-4a, N2 or N3, M0.

Stage 4

  • Stage 4A: Cancer has spread to the abdominal or pelvic wall, or cancer has spread to lymph nodes above the main pelvic arteries (any T, any N, M1a).
    • The TNM characteristics are T4b, any N, M0 or any T, any N, M1a.
  • Stage 4B: Cancer has spread to at least one distant organ.
    • The TNM characteristics are any T, any N, M1b.

Bladder cancer that has spread to surrounding reproductive organs or pelvic lymph nodes is called locally advanced disease. When it’s spread to other body parts—such as the liver, bones, lungs or lymph nodes outside the pelvis—it’s called metastatic disease.

Staging after recurrence

If cancer returns after treatment, called recurrent cancer, doctors may run tests again to understand more about the recurrence, including its stage and grade. This process is called restaging, and it helps doctors determine the best course of action to treat a cancer recurrence. The new stage also has a lowercase “r” in front of it to indicate that it’s the stage of the recurrence, not necessarily the original cancer’s stage.

Grade

In addition to the stage, doctors may talk about the bladder cancer’s grade. Grade describes how bladder cancer cells look under a microscope.

  • Low-grade cancers, or well-differentiated cancers, resemble regular bladder cells.
  • High-grade cancers, also called poorly differentiated or undifferentiated cancers, don’t look as much like normal bladder cells and are more likely to become invasive, spread to other body parts or return after treatment.

Throughout a bladder cancer diagnosis, staging and treatment, there may be a lot of new terminology and information to absorb. Patients should ask any questions they have to stay as informed as possible about the type of cancer and treatment options.

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