Bladder Cancer Stages

A bladder cancer's stage indicates how far it has spread within the bladder, to nearby tissues, and to other organs. The stage of a cancer is one of the most important factors in selecting treatment options, as well as the most significant (but not the only) factor in predicting prognosis.

A staging system is a standard way to describe the extent to which a cancer has spread. The most commonly used system in the United States is called the TNM System of the American Joint Committee on Cancer (AJCC). The TNM System describes the extent of the primary tumor (T), the absence or presence of spread to nearby lymph nodes (N), and the absence or presence of spread (metastasis) to distant organs (M).

Some doctors may also use other staging systems that use the letters A, B, C, and D to describe the extent of a bladder cancer. Be sure to ask your cancer care team to explain your stage in a way that you understand, so you will be able to make informed choices about your treatment. The T, N, and M categories described below are based on the 2002 revision of AJCC stages for bladder cancer.

Bladder Tumor (T) Categories

There are actually two types of T classifications for bladder cancer.

• The clinical stage is the one assigned by the doctor based on the results of all diagnostic tests and biopsies.
• The pathologic stage is based on surgical removal and examination of the tumor and other tissue.

The clinical stage is used in making treatment decisions. However, the clinical stage can underestimate how far the cancer has spread. The pathological stage assigned after surgery is more accurate in predicting the patient’s outlook for survival.

Bladder cancer often affects many areas of the bladder at the same time. If the biopsy finds multiple cancers, the letter “m” is added to the appropriate T category.

When bladder cancer is found in the very superficial lining of the bladder and does not invade surrounding tissues, it is called carcinoma in situ (CIS). When CIS is found, the letters "i and s" may be added.

• TX: Primary tumor cannot be
  determined
• T0: No evidence of primary tumor
• Ta: Noninvasive papillary carcinoma
• Tis: Carcinoma in situ (CIS); noninvasive flat carcinoma
• T1: Tumor has grown below the urothelial lining but not as deep as the muscle tissue
• T2: Tumor invades muscle
  • T2a: Tumor invades superficial
    muscle (inner half)
  • T2b: Tumor invades deep muscle (outer half)
• T3: Tumor invades fatty tissue that surrounds the bladder
• T3a: The tumor’s spread to fatty
  tissue surrounding the bladder can only be seen by using a microscope
• T3b: The tumor’s spread to fatty tissue surrounding the bladder is large enough to be seen on imaging tests or to be seen or felt by the surgeon
• T4: Tumor invades any of the following: prostate, uterus, vagina, pelvic wall, or abdominal wall
  • T4a: Tumor invades the prostate in men and the uterus and/or vagina
    in women
  • T4b: Tumor invades the pelvic wall and/or the abdominal wall

Regional Lymph Node (N) Categories

• NX: Regional (nearby) lymph nodes (in the pelvis) cannot be evaluated
• N0: No regional lymph node spread
• N1: Spread to a single lymph node, which is 2 cm ( 4/5 inch) or smaller
• N2: Spread to a single lymph node, larger than 2 cm but smaller than 5 cm (2 inches); or in multiple lymph nodes, none larger than 5 cm
• N3: Spread to a lymph node larger than 5 cm

Distant Metastasis (M) Categories

• MX: Distant metastasis cannot be determined
• M0: No distant metastasis
• M1: Distant metastasis

Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping to assign an overall stage of 0, I, II, III, or IV, with stage 0 being the least serious (or earliest stage) and stage IV being the most serious (or advanced stage).

AJCC Stage Groupings

Bladder Cancer TNM Stages
 

Summary of Bladder Cancer TNM Stages

Stage 0a: The cancer is a noninvasive papillary carcinoma. It has grown toward the hollow center of the bladder but has not invaded into the muscle or connective tissue of the bladder wall.

Stage 0is: The cancer is a noninvasive flat carcinoma, also known as flat carcinoma in situ (CIS). The cancer affects the lining layer of the bladder but has neither grown inward toward the hollow part of the bladder nor invaded the muscle or connective tissue of the bladder wall.

Stage I: The cancer has invaded the layer of connective or supporting tissue under the lining layer of the bladder. But the cancer has not spread to the thick layer of muscle in the bladder wall. The cancer has not spread to the lymph nodes or to any other organs.

Stage II: Cancer has invaded the thick muscle layer of the bladder wall. But the cancer has not grown completely through the muscle to reach the layer of fatty tissue that surrounds the bladder. The cancer has not spread to the lymph nodes or to any other organs.

Stage III: The cancer has invaded completely through the muscle layer of the bladder and into the layer of fatty tissue that surrounds the bladder. It may have spread into the prostate, uterus, or vagina. The cancer has not spread to the lymph nodes or to other organs.

Stage IV: The cancer has spread through the bladder wall to the pelvic or abdominal wall and/or has spread to lymph nodes or to distant organs such as bones, liver, or lungs.

Grades

Bladder cancers are also given a grade, based on how the cancer looks under the microscope. There are 3 grades: low (G1), intermediate (G2), and high (G3). Low-grade cancers look more like normal bladder tissue, which suggests that they will not be very aggressive. High-grade cancers look much less like normal tissue. They are more likely to invade the bladder wall and to spread outside the bladder.

Although the grade of bladder cancer does not affect the stage of the cancer, it does affect the recommended treatment options, especially for noninvasive cancers.

BLADDER CANCER WORK-UP

TYPES OF BLADDER CANCER TREATMENT

For more information on these treatment guidelines, or on cancer in general, call the NCCN at 1-888-909-NCCN or the American Cancer Society at 1-800-ACS-2345. Or you can visit these organizations’ web sites at www.cancer.org (ACS) and www.nccn.org (NCCN).

© 2005 by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS). All rights reserved. The information herein may not be reproduced in any form for commercial purposes or downloaded and stored in any information-retrieval system without the express written permission of the NCCN and the ACS. Single copies of each page may be printed out for personal, noncommercial use only.