Bladder cancer isn’t always the same for everyone. For about 75 percent of people diagnosed, the cancer stays in the bladder’s inner lining and doesn’t spread to the other layers, such as the muscle or fatty outer layer. This type is called non-muscle-invasive bladder cancer (NMIBC), or superficial bladder cancer. While it’s considered an early-stage cancer, NMIBC still needs careful monitoring and treatment to keep it from coming back or getting worse. This article will review NMIBC, focusing on how it’s diagnosed and treated.

What Is NMIBC?

NMIBC tumors can grow in two ways. Some grow into the hollow part of the bladder and are called noninvasive papillary carcinoma. Others grow flat along the lining of the bladder and are known as noninvasive flat carcinoma or carcinoma in situ (CIS).

While NMIBC is not as aggressive as bladder cancer that spreads deeper, some tumors are more likely to come back after treatment. Doctors look at factors like tumor size, number, and how abnormal the cells look to decide on the best treatment and follow-up care.

How Is NMIBC Staged?

Doctors use the American Joint Committee of Cancer (AJCC) staging system, called TNM, to describe how far cancer has spread. The TNM system describes the tumor size (T), whether the cancer has spread to the lymph nodes (N), and whether the cancer has metastasized (spread) to other parts of the body (M). This information helps your cancer care team predict which treatments may work the best for you.

The TNM system classifies NMIBC as stage 0 and stage 1. In these stages, cancer remains in the inner bladder lining and has not spread to lymph nodes, nearby organs, or other body parts.

People with stage 0 bladder cancer may have noninvasive papillary carcinoma (stage 0a) or CIS (stage 0is).

In stage 1 bladder cancer, the tumor has begun to spread to the layer of connective tissue beneath the bladder wall but hasn’t spread to the muscle.

What Are the Symptoms of NMIBC?

The most common symptom of NMIBC is hematuria (blood in your urine). When hematuria is caused by NMIBC, it usually doesn’t cause any pain.

Blood in your urine may be your only symptom of NMIBC. You may notice it as a change in urine color, such as pink, orange, or red. The color change may not be noticeable every day. However, in some cases, blood in the urine isn’t noticeable and may only be found with laboratory tests.

If NMIBC progresses to a more advanced stage of bladder cancer, you may have additional symptoms, including:

• Urinating more often or at night
• Needing to urinate urgently
• Experiencing pain or burning when urinating
• Having difficulty urinating

How Is NMIBC Diagnosed?

NMIBC can be hard to diagnose because it doesn’t always cause noticeable symptoms. Additionally, bladder cancer isn’t the most common reason someone might have blood in their urine. During the process of diagnosing bladder cancer, your healthcare provider may test you for other common causes of blood in the urine, such as a urinary tract infection, enlarged prostate, or kidney stones.

Several tests can help your healthcare team diagnose NMIBC.

Health History and Physical Exam

Your current and past health history can help your healthcare provider learn more about your symptoms and risk factors.

It’s important to talk to your healthcare provider right away if you have any urinary symptoms. This can help you get diagnosed earlier when treatment is more likely to cure you.

Your healthcare provider may ask questions to learn if you have risk factors for developing bladder cancer. According to the National Cancer Institute, these risk factors may include:

• Male sex
• Age greater than 55
• Smoking
• Exposure to certain chemicals at work
• Family history of bladder cancer
• Previous radiation therapy in the pelvic region
• Treatment with certain anticancer drugs

Urine Tests

If you have blood in your urine, your healthcare provider may order several different urine tests to find the cause, including:

• Urinalysis — Looks for substances, such as blood, in your urine
• Urine cytology — Examines urine for cancer cells
• Urine culture — Identifies bacteria in your urine
• Urine tumor marker tests — Checks for substances made by cancer cells

If your urine test results suggest you may have bladder cancer, you’ll be referred to a urinary system specialist called a urologist for more testing.

Tests To Diagnose NMIBC

Although your health history and urine tests are helpful to rule out other causes of your symptoms, they’re not enough to make a definite diagnosis. To diagnose NMIBC, a urologist must look inside the bladder with special equipment and examine a sample of bladder tissue under the microscope.

Cystoscopy

A cystoscopy is a procedure that lets your urologist see inside your bladder. They do this by inserting a long, thin tube called a cystoscope into your bladder through your urethra. The urethra is the opening where urine leaves your body.

The tube has a light and a camera so your urologist can look for any areas inside your bladder that may look abnormal. If an abnormal area is found, they can use a special tool on the end of the cystoscope to remove a tissue sample (called a biopsy).

Transurethral Resection of Bladder Tumor

A cystoscopy is usually used to make the first diagnosis of bladder cancer. However, another procedure called a transurethral resection of bladder tumor (TURBT) is often done to confirm the diagnosis. A TURBT is similar to a cystoscopy. However, during this procedure, your urologist will remove the tumor and some surrounding tissue. The tissue sample taken from a TURBT helps your doctor learn how far the cancer has spread.

Tests To Check if Cancer Has Spread

Imaging tests can check if the cancer has spread to other parts of the body, such as the lymph nodes or other organs. Imaging tests for bladder cancer may include:

• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI) scan
• Ultrasound
• Chest X-ray
• Positron emission tomography (PET) scan
• Bone scan

How Is NMIBC Treated?

A TURBT is a common treatment for NMIBC. Although TURBT is used in the diagnosis process, this may be the only treatment some people with NMIBC need if the entire tumor is removed. However, a second TURBT may be needed to make sure all of the tumor is removed.

If your NMIBC has a high risk of recurring (returning), you may need additional treatment. Your cancer care team will use certain features of your cancer to determine your risk group. Concerning features of NMIBC may include:

• A tumor larger than 3 centimeters
• Multiple low-grade tumors
• High-grade tumors
• A tumor that’s growing into the connective tissue
• Bladder cancer that’s come back after treatment
• CIS

If you have a single papillary tumor less than 3 centimeters, it’s usually considered low-risk NMIBC. If you have just one concerning feature, it’s considered intermediate-risk NMIBC. If you have more than one concerning feature, it’s considered high-risk NMIBC.

People with low-risk NMIBC may not need any other treatment after a TURBT. However, those with intermediate- or high-risk NMIBC may need additional treatment.

Treatment for Intermediate-Risk NMIBC

Intravesical therapy is a common treatment after TURBT for intermediate-risk NMIBC. During this treatment, a liquid drug is placed into the bladder through a catheter (tube) inserted into your urethra. The liquid drugs used in intravesical therapy include:

• Immunotherapy — Such as Bacillus Calmette-Guérin (Tice BCG), nadofaragene firadenovec-Vncg (Adstiladrin), and nogapendekin alfa inbakicept (Anktiva)
• Chemotherapy — Such as gemcitabine (Gemzar) and mitomycin (Mutamycin)

Most people start intravesical therapy a few weeks after a TURBT. It’s usually given once weekly for six weeks. However, some people will continue to get intravesical therapy for up to one year to prevent recurrence.

Treatment for High-Risk NMIBC

Intravesical therapy with BCG is a common treatment after TURBT for people with high-risk NMIBC. This treatment can continue for up to three years to prevent recurrence.

If intravesical BCG doesn’t work, or if you have very high-risk features, your cancer care team may recommend additional treatments, such as:

• Radical cystectomy (bladder removal surgery)
• Intravesical chemotherapy
• Intravesical immunotherapy with another drug
• Pembrolizumab (Keytruda)

Follow-Up After Treatment

No matter what kind of treatment you have, your cancer care team will follow you closely after treatment to make sure the cancer doesn’t come back. After treatment, it’s recommended to have a cystoscopy every three months for several years to check for signs of recurrence.

Talk to your cancer care team about your follow-up plan after you finish treatment.

Talk With Others Who Understand

MyBladderCancerTeam is the social network for people with bladder cancer and their loved ones. On MyBladderCancerTeam, members come together to ask questions, give advice, and share their stories with others who understand life with bladder cancer.

Have you or a loved one been diagnosed with NMIBC? What has your treatment journey been like? Share your experience in the comments below, or start a conversation by posting on your Activities page.