By Jennifer Welsh 

Updated on August 29, 2023

 Medically reviewed by Lindsay Cook, PharmD

When you are first diagnosed with bladder cancer, your doctors will perform tests to determine the stage and grade of your disease. The bladder cancer staging and grading processes help your doctors make treatment decisions and estimate your chance of recovery.  

Bladder cancer is a growth that starts in the inner wall of the bladder, the organ that collects and expels urine created by the kidneys. The bladder has three layers of muscular walls that make up its structure.¹ A cancerous growth in the bladder can grow uncontrollably and start spreading to other parts of the body.

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When doctors first diagnose a cancerous tumor of any kind, they assess how much it has grown, how far it has spread in the body, and how abnormal, or wild, the cancerous cells in the tumor look. These assessments are used to determine cancer’s stage (0 to IV) and grade.²

Doctors use the staging information to compare treatment options and patient outcomes. Staging and grading also important in determining your eligibility for cancer treatment clinical trials.²

Early Detection

If cancers are caught early, they are easier to treat and cure. When they’re caught later, after they’ve grown and spread, they’re more difficult to treat and more likely to be deadly. 

This article will cover how bladder cancers are staged and graded, the bladder cancer staging system, and the stages of bladder cancer, as well as some frequently asked questions about bladder cancer staging. 

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Bladder Cancer Grading

Doctors use a variety of tests to diagnose bladder cancer and determine its grade and stage. These include blood tests, imaging tests that look inside the body, and samples of the tumors called a bladder biopsy, usually taken during surgery. 

A specialist doctor called a pathologist analyzes the tumor samples under the microscope. Often assisted by pathology lab professionals, the pathologist takes pieces of the tumor and shaves them into thin slices, coloring them with special dyes to highlight structures within the cell.

The pathologist determines the sample’s grade by how wild or abnormal the cells in the cancer look compared with the normal cells around them. The grades go from grade 1 (mostly normal) to grade 3 (very abnormal).³

Symptoms of Bladder Cancer

Symptoms of bladder cancer are relatively common symptoms of various diseases and are easy to miss. The most common symptom of bladder cancer is reddish or brownish-colored urine from blood in the urine. Other symptoms include the frequent urge to urinate, pain while urinating, and pain in the back or pelvis.⁴

The TNM System of Bladder Cancer Staging

The size of the tumor and whether it has spread are used to ascertain the stage. Cancer staging specifics are determined by guidelines set by the American Joint Committee on Cancer’s system, named the TNM staging system.²

The TNM system has three parts:

• T stands for tumor. This number indicates how large the tumor is and how much it has grown into nearby tissues.

• N stands for nodes. This number indicates if the tumor has spread to lymph nodes, where the lymph nodes are located, and how many lymph nodes are impacted.

• M stands for metastasis. This number indicates if the tumor has spread to other organs.

Metastasis

The cancer spreads from the original location through a process called metastasis. When cancer spreads, it’s called metastatic cancer or a metastatic tumor. This spreading can happen between tissues, or through the fluids of the blood or lymphatic systems.³

T scoring is from 0 to 4, and also special categories of Ta and Tis. N is scored from 0 to 3. M is either 0 or 1. An X means that that characteristic couldn't be measured.³

Stage Never Changes

A cancer stage never changes from when it was first diagnosed. If cancer improves or worsens, it will be the same stage cancer.²

Stage 0 Bladder Cancer

Stage zero bladder cancers are called noninvasive papillary carcinoma and carcinoma in situ. They’re precancerous lesions that could develop into more serious cancers if not treated.³

These growths develop on the inner lining of the bladder. Noninvasive papillary carcinoma, also called stage 0a, forms long, thin growths into the empty space inside the bladder. 

Carcinoma in situ, also called stage 0is bladder cancer, forms flatter growths that tend to be of a wilder “grade.” It is considered a more aggressive disease and is more likely to spread into the muscular walls of the bladder.⁵

According to the National Cancer Institute’s SEER database of cancer statistics, about half (51%) of bladder cancers are diagnosed at stage 0.⁶

Treatment

Stage 0 bladder cancer is typically successfully treated with a surgery called transurethral resection (TUR) with fulguration. 

The surgery uses a lighted camera that is threaded up the urethra—the tube through which urine usually exits the body. The tube has tools on it that let the surgeon remove the tumor, take a biopsy sample, and burn away any remaining cancerous cells, a procedure known as fulguration.⁷

Surgery is typically followed up with chemotherapy inside the bladder or an immunotherapy called Bacillus Calmette-Guerin (BCG) therapy. When treatment is given into the bladder, it's called intravesically administered treatment.

BCG is a unique immunotherapy treatment that uses germs related to those that cause tuberculosis to activate your body's immune response and attack bladder cancer.

If BCG therapy is unsuccessful, another treatment option includes Adstiladrin (nadofaragene firadenovec-vncg). Adstiladrin is the first gene therapy approved for adults with high-risk, non-muscle invasive bladder cancer that hasn't responded to BCG therapy, the standard treatment.

Stage I Bladder Cancer

Stage I bladder cancers are cancerous tumors that have spread from the inner layer of the bladder into the connective tissue layer just under it. ³

These tumors haven’t yet reached the muscular layers of the bladder, so they’re often called non-muscle-invasive bladder cancer. Some cases of non-muscle-invasive bladder cancer progress to muscle-invasive bladder cancer, which is more serious.

According to SEER, a third (34%) of bladder cancers are diagnosed when they’re local, when they haven’t spread beyond the organ they developed in, stage I and II.⁶

Treatment

Non-muscle-invasive bladder cancers are treated with surgery, called transurethral resection of bladder tumor (TURBT), or TUR with fulguration, to remove any visible cancer. This treatment is usually followed by chemotherapy or BCG therapy inside the bladder.⁷

In some cases, a more extensive surgery called a radical cystectomy is recommended. Cases this may be used for include those in which the tumors in the bladder take over a large part of the organ. This surgery removes the bladder and any nearby cancerous lymph nodes or tissues.

Stage II Bladder Cancer 

Stage II bladder cancer is also known as muscle-invasive bladder cancer. These tumors have spread into the muscular walls of the bladder. Stage II cancers are more likely to spread to other parts of the body.³

Approximately 20% of newly diagnosed bladder cancer cases are muscle-invasive.⁸

Muscle-Invasive Tumors

How far the tumor has invaded into the muscular wall of the bladder plays a central role in staging. Cancers that have grown into the bladder wall (muscle-invasive tumors) generally have poorer outcomes. The same applies to having larger tumors or numerous tumors.

Treatment

Stage II and stage III bladder cancer are typically treated with surgeries to remove all or part of the bladder and any local tissues that cancer may have spread to. Some patients may only need a partial removal of the bladder or TUR and fulguration.⁷

Sometimes treatments like chemotherapy and external-beam radiation therapy are also used. If chemotherapy is recommended to shrink the bladder tumors before surgery, it’s referred to as neoadjuvant therapy.

Stage III Bladder Cancer

Stage III bladder cancers have started to spread away from the bladder itself into either local or regional organs or into lymph nodes in the pelvis. It’s divided into stage IIIA and stage IIIB.³

Stage IIIA bladder cancer has either:

• Spread into the fat around the bladder or into the reproductive organs, but not to the lymph nodes 

• Spread from the bladder to one lymph node in the pelvis (not near major arteries)

Stage IIIB cancer has also spread. To be defined as stage IIIB, cancer needs to be found in either:

• More than one lymph node far from major arteries

• One or more lymph nodes near the major arteries

According to SEER, 7% of bladder cancer cases are diagnosed when they’ve reached stage III, or “regional” stage.⁶

Stage IV Bladder Cancer

Stage IV cancer has metastasized or spread to major organs in other parts of the body. This is often called metastatic cancer. About 5% of bladder cancer cases are diagnosed after they’ve already spread to distant organs, according to SEER.⁶

Stage IV bladder cancer is divided into stage IVA and IVB. IVA cancer has spread either:³

• Into the wall of the abdomen or pelvis

• Into multiple lymph nodes near the major arteries of the pelvis

IVB bladder cancer has spread to other organs, which can include the lungs, bones, and liver.

Treatment

When a patient is diagnosed with stage IV or metastatic bladder cancer, doctors will likely use a combination of chemotherapy, surgery, immunotherapy, and radiation to reduce symptoms and prolong life.⁷

Coping

Late-stage bladder cancer doesn't have very good outcomes. According to SEER, if bladder cancer has metastasized before it is detected, there's only about a 6.4% chance of a patient surviving five years after being diagnosed.⁶

New types and combinations of treatment for bladder cancer are being tested in clinical trials. Talk to your doctor about your options and be honest with your care team about your thoughts and feelings—they're there to help make the best decisions and provide the best options for you.

Summary

When you are diagnosed with bladder cancer, it will be graded and staged. The grade (1 to 3) depends on how abnormal the cells in the cancer look compared with the normal cells around them. The stage will be determined by how invasive the cancer is and how far it has spread (0 to IV). The grade and stage help guide treatment options.