Bladder cancer is categorized into stages to describe how much the cancer has grown and if it has spread to other parts of the body. Knowing the stage of bladder cancer helps doctors choose the best treatment and helps people with bladder cancer have a clearer idea of what to expect. Each stage is different, from early, noninvasive cancer to more advanced stages where cancer spreads to other parts of the body.

If you or someone you love has been diagnosed with bladder cancer, it’s important to learn about the staging system. In this article, we’ll explain the different bladder cancer stages and symptoms to watch for at each one.

The TNM Staging System

The TNM staging system is the standard tool for staging bladder cancer. It was developed by the American Joint Committee on Cancer (AJCC). It helps doctors describe the extent of the cancer and guide treatment decisions. The TNM system evaluates three main factors.

• Tumor (T) — This measures how far the tumor has grown, from surface-level cancer to invasion of nearby organs. Numbers or letters are sometimes added to provide more specific details about the tumor’s size or extent. For example, Tis means cancer cells are only on the surface (carcinoma in situ).
• Node (N) — This tells if cancer has spread to nearby lymph nodes, which are small, bean-shaped structures that help filter harmful substances and support the immune system. Numbers are added to show how many lymph nodes are affected and how far the cancer has spread from the bladder.
• Metastasis (M) — This indicates whether the cancer has spread to other organs, like the lungs or liver. Numbers or letters are added to show the presence and location of distant spread.

By combining these elements, doctors assign an overall stage from 0 (early stage) to 4 (advanced stage) to describe the progression and severity of the disease. Stages are often written in Roman numerals, such as stage IV for stage 4.

Stage 0 Bladder Cancer

In stage 0, the cancer is only on the surface of the inner lining of the bladder. It hasn’t spread deeper into the bladder wall or other areas outside the bladder.

Stage 0 is divided into two types of bladder cancer:

• Stage 0a (noninvasive papillary carcinoma, Ta) — This type grows on the bladder lining in thin shapes resembling fingers.
• Stage 0is, also called noninvasive flat carcinoma (Tis) — This type is flat and stays confined to the bladder lining.

At this stage, there is no cancer involvement of lymph nodes (N0) or distant spread to other organs (M0). Many people with stage 0 bladder cancer have no symptoms. However, some may experience hematuria (blood in the urine) or feel the need to urinate more often. When detected early, stage 0 bladder cancer is highly treatable, with excellent outcomes in most cases.

Stage 1 Bladder Cancer

Stage 1 bladder cancer occurs when the cancer has grown beyond the bladder’s inner lining into the connective tissue layer, which provides support and structure. However, it has not yet invaded the muscle layer of the bladder. This stage is referred to as non-muscle-invasive bladder cancer (NIMBC) and is considered early and localized. Prompt treatment is essential to prevent further spread.

The TNM staging for stage 1 bladder cancer is T1-N0-M0:

• T1 — The tumor has invaded the connective tissue but not the muscle layer of the bladder wall.
• N0 — No cancer is found in nearby lymph nodes.
• M0 — The cancer has not spread to distant organs or tissues.

Symptoms of Stage 1 Bladder Cancer

At stage 1, bladder cancer symptoms are often noticeable but can vary in intensity. Common signs of bladder cancer during stage 1 include:

• Hematuria — Blood in the urine, which may appear pink, red, or brown
• Polyuria — Needing to urinate more often than usual, which can disrupt daily activities or sleep
• Dysuria — Painful or uncomfortable urination, often described as a burning, stinging, or sharp sensation

Treatment for Stage 1 Bladder Cancer

Although stage 1 bladder cancer has not spread to lymph nodes or distant organs, early treatment is critical. Stage 1 bladder cancer treatment typically includes:

• Transurethral resection (TURBT) — A minimally invasive procedure to remove the tumor
• Additional therapies — May include intravesical treatments (medications placed directly in the bladder) to reduce the risk of recurrence (cancer returning)

Stage 2 Bladder Cancer

In stage 2 bladder cancer, the tumor has grown deeper into the bladder wall and invaded the muscle layer. However, it hasn’t yet spread to nearby lymph nodes or other organs.

The TNM system defines stage 2 bladder cancer as T2-N0-M0:

• T2 — The cancer has invaded the muscle layer of the bladder wall — either the inner part (T2a) or the outer part (T2b) — but hasn’t spread through the muscle to the fatty tissue surrounding the bladder.
• N0 — No cancer is found in nearby lymph nodes.
• M0 — The cancer has not metastasized to other parts of the body.

Symptoms of Stage 2 Bladder Cancer

Symptoms of bladder cancer during stage 2 are often more severe and persistent than in earlier stages. Common symptoms include:

• More frequent or noticeable blood in the urine
• More painful or persistent pain while urinating
• Pain in the pelvis or lower abdomen (belly) — Often described as a dull or sharp ache
• Difficulty with urination — May include a weak urine stream, straining, or trouble emptying the bladder fully

Treatment for Stage 2 Bladder Cancer

Stage 2 bladder cancer requires aggressive treatment to prevent further spread. Common treatments include:

• Partial cystectomy — Surgery to remove part of the bladder, used when the tumor is confined to a specific area of the bladder and can be removed
• Radical cystectomy — Surgery to remove the entire bladder, in cases in which the cancer has invaded the muscle layer or is widespread within the bladder
• Chemotherapy — May be used before surgery (called neoadjuvant chemotherapy) to shrink the tumor for easier removal or after surgery (adjuvant chemotherapy) to lower the risk of recurrence

Stage 3 Bladder Cancer

At stage 3, the tumor has grown through the muscle layer of the bladder wall and into surrounding tissues, such as the fatty layer or nearby organs like the prostate, uterus, or vagina. The cancer may involve one or more nearby lymph nodes but has not spread to distant organs. At this stage, it’s considered advanced bladder cancer and is harder to treat.

The TNM system defines stage 3 bladder cancer using the following classification:

• T3 or T4 (usually) — The bladder tumor has grown into the fatty layer around the bladder (T3) or into nearby organs like the prostate, uterus, or vagina but not into the pelvic or abdominal wall (T4a). In rare cases, a tumor classified as T2 (fully grown into the muscle layer) may qualify as stage 3.
• Any N — The cancer may or may not involve nearby lymph nodes. N0 means no lymph node involvement; N1 means cancer is found in a single lymph node near the bladder; N2 indicates multiple lymph nodes near the bladder in the pelvic region are affected, and N3 means cancer has spread to lymph nodes farther from the bladder, such as in the groin (inguinal nodes) or other distant areas.
• M0 — There is no evidence of cancer spreading to distant organs or tissues.

Symptoms of Stage 3 Bladder Cancer

Common symptoms of stage 3 bladder cancer are more intense and may affect the whole pelvic area. In addition to symptoms seen in earlier stages, such as blood in the urine or painful urination, new or worsening symptoms may include:

• Persistent pelvic pain or pressure — This is often a dull or sharp discomfort.
• Edema (swelling in the legs or feet) — This occurs when cancer interferes with lymphatic drainage, the body’s system of moving fluid through lymph vessels and nodes. Blockage or damage to these pathways causes fluid buildup in the tissues, leading to swelling.
• Urinary difficulty — This may include trouble starting urination, inability to empty the bladder completely, or loss of bladder control.

Treatments for Stage 3 Bladder Cancer

Stage 3 cancer typically requires a combination of treatments. The goal is to remove as much of the cancer as possible and prevent it from spreading further. Your doctor will tailor your treatment plan based on the size and location of your tumor, as well as your overall health.

Treatments at this stage can include:

• Radical cystectomy — As noted, this refers to removal of the entire bladder, along with surrounding lymph nodes, and nearby affected organs (if necessary).
• Chemotherapy — Chemotherapy at this stage is generally more aggressive than at earlier stages. Unlike earlier stages, systemic chemotherapy (affecting the whole body) is typically used to address cancer that may have spread beyond the bladder.
• Radiation therapy — This may involve external beam radiation therapy (directed from outside the body) or brachytherapy (radiation placed directly in or near the bladder).
• Immunotherapy — Immunotherapy medications boost the immune system to fight cancer cells. These treatments are generally used in advanced stages, as they can cause significant side effects.

Stage 4 Bladder Cancer

Stage 4 bladder cancer is the most advanced stage and is often referred to as metastatic bladder cancer. At this stage, the cancer has either spread beyond the bladder to distant lymph nodes or organs (such as the liver, lungs, or bones) or has invaded nearby structures like the prostate, uterus, or pelvic wall. It may also involve multiple lymph nodes, making treatment more complex.

The TNM system defines stage 4 bladder cancer as follows:

• Any T — The tumor may or may not have grown through the bladder wall into nearby tissues or organs.
• Any N — The tumor may or may not have spread to nearby or distant lymph nodes.
• M1 — The tumor has spread to distant lymph nodes (M1a) or distant organs (M1b).

Symptoms of Stage 4 Bladder Cancer

At this stage, symptoms may be widespread and more severe, often affecting multiple areas of the body. These may occur in addition to symptoms seen in earlier stages, including hematuria or difficulty urinating. New or worsening symptoms can include:

• Severe pelvic, back, or abdominal pain — Often caused by tumor growth pressing on nerves or surrounding organs, leading to chronic discomfort or sharp, localized pain
• Bone pain — A result of cancer spreading to the bones, which can weaken the bone structure and increase the risk of fractures (breaks)
• Edema — Often more severe than in earlier stages, as cancer involvement of distant lymph nodes or major veins can lead to greater disruption in lymphatic drainage and circulation
• Unexplained weight loss — Linked to cancer-related metabolic changes or a decrease in appetite, often referred to as cancer cachexia (a wasting syndrome)

Treatment for Stage 4 Bladder Cancer

Treatment for stage 4 bladder cancer focuses on controlling the disease symptoms and improving quality of life. At this advanced stage, surgery is rarely an option because the cancer has spread too much for complete removal. Treatment options may include:

• Chemotherapy — At stage 4, chemotherapy is typically systemic and more aggressive than at earlier stages, and it generally focuses on managing metastases.
• Immunotherapy — Immunotherapy is frequently used at stage 4 to enhance the immune system's ability to fight cancer throughout the body. At stage 4, it addresses widespread disease and is often used when chemotherapy is not effective or as a first-line treatment for certain people.
• Radiation therapy — Radiation therapy at this stage is generally palliative and aimed at relieving specific symptoms like pain, bleeding, or pressure caused by tumors.
• Palliative care — This focuses on improving quality of life by addressing physical, emotional, and practical challenges. Approaches include pain management medication, nutritional support, emotional and psychological support, and practical assistance to help with mobility issues, arranging at-home care, and accessing hospice services.

While stage 4 bladder cancer is difficult to treat, clinical trials and advanced therapies may offer hope for some people. Follow up with your health care team to learn more about what treatment options are available to you.

Talk to Your Doctor

If you or a loved one has symptoms of bladder cancer, don’t wait to see a doctor. An early-stage cancer diagnosis leads to better outcomes. Knowing the stage of cancer can help you and your care team decide on the best treatment plan. Stay informed, listen to your body, and reach out for support when you need it.

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