What are the signs and symptoms of bladder cancer?
Initial symptoms may include blood in the urine (either where you can see the blood or with a test that detects minute amounts of blood), increased frequency of urination, a burning sensation while urinating and unexplained weight loss.  If you are experiencing any of these symptoms you should consult with your physician.

How is bladder cancer diagnosed?
Diagnostic procedures provide valuable in-depth information regarding the staging and grading of cancer. The following investigations are done sequentially and the reports obtained are collated to form a final picture and the treatment selected.

• Cystoscopy
• Biopsy
• Cytology
• TUR-BT (Trans urethral resection of bladder tumors)

What is staging of bladder cancer? Why does the doctor need to know it?

Staging classifies the extent of cancer. It is expressed as a number indicating how far out the tumor has gone. The bladder lining, the muscle wall, surrounding organs (prostate in male, vagina/uterus in female) and the pelvic wall or lymph nodes are the four milestones doctors need to know have been crossed or not. Staging is determined by different diagnostic tests.

These include some or all of the following:

• Pathologic examination of the depth of invasion
• IVU
• Chest X Ray
• Liver function tests
• CT scan of abdomen and pelvis
• MRI
• Bone scan, if bone pain is present or increased alkaline phosphatase in blood

The American Joint Committee on Cancer (AJCC) has designated staging using the TNM classification to define bladder cancer:

• T is for Tumor and indicates how big it is and exactly where it has spread; higher the T number, bigger the size and spread.
• N is for [Lymph] Nodes meaning whether the cancer has spread to small glands that filter out cancer cells but end up getting involved themselves. Actually each organ has its own natural drainage system.
• M is for Metastasis meaning whether the cancer has spread to distant areas of the body.

Stage 0 means either a flat tumor or very small tumor.
Stage I  The cancer is just below the top layer of the bladder's inner lining. 
Stage II  The bladder's own muscle layers have been invaded by cancer cells. This is deeper than I but not outside the bladder.
Stage III  Now it's extending also outside the bladder. Tumor invades any of the following: the prostate in the male, the uterus and/or vagina in the female.
Stage IV  The pelvic wall, or abdominal wall is involved. If the lymph nodes are involved it is stage IV. If the cancer has spread in the body, called metastasis (M1) it is taken as Stage IV.

Combinations of the above system are used to determine the prognosis (likelihood that the patient will come out well) and make treatment decisions. Treatment is decided by stage and grade.

What is grading? Is a patient's cancer grade important to know?

Grading is a visual estimate of how aggressive the tumor cells appear under a microscope. Grade basically reveals how abnormal the cancer cell really is and is reported as low or high. As a general rule, higher grade cells often grow faster, invade deeper and spread sooner- they are life threatening. Low grade bladder cancers grow slowly, rarely invade and rarely spread- they are usually a nuisance. The hospital's pathologist reports the grade after the urologist takes a sample of the suspicious growth by biopsy.

What is Cytology? A sample of the urine is checked for presence or absence of cancer cells. If present, then the level of abnormality is checked. This gives an idea regarding the severity of the cancer and directs treatment options.

What is Cystoscopy? A thin lighted tube is manually inserted through the urinary tract or urethra to examine the inner surface of the bladder. The cystoscope is regarded as very reliable by surgeons as it gives a direct approach to note the presence of a visible tumor. Cysto facilitates other procedures as follows.

• A 'bladder wash' is additionally used in selected cases to loosen the cells of the inner lining of the bladder to increase the yield of cells for cytology exam.
• A 'biopsy' is taken whenever abnormal tissue is located. Some bleeding is always expected when biopsy is taken, so the lining of the bladder is cauterized after taking the biopsy. Some anesthesia is usually required and it maybe local or general.

The biopsy test reveals for sure whether the abnormal growth is cancer or not.

What to expect after cystoscopy? A couple of common symptoms are expected after cystoscopy. You will feel irritation upon urination and notice passage of a small amount of blood in the urine. These are not a cause of concern. However, if the bleeding is excessive, your urologist needs to be notified. You should discuss with your urologist what ‘excessive bleeding’ really means. Urine can have red color even with a relatively small amount of blood in it.

Fever and chills can be felt by some after the procedure. The sources of these are the bacteria already present inside the urethra. Urological equipment, having been rendered sterile, is usually not the source. Antibiotic pills may be prescribed for several days to prevent development of a full fledged urinary tract infection.

Cystoscopy helps in identifying the type of tumor present inside the bladder. It distinguishes the ‘nuisance’ superficial tumor, from the ‘deadly’ deeper ones. The superficial ones are easier to treat, less dangerous and more common than the deeper ones. The results of various tests, like the cystoscopic biopsy, for example, if taken during the procedure, are usually reported in a week’s time.

What is Intravenous Pyelogram (or IVP) and Intravenous Urogram (or IVU)? A chemical which appears in a different color on the x-ray is injected into the arm vein which later filters via the kidney into the bladder. Surface defects of the bladder lining and any anatomical obstruction of the upper urinary pathway are reliably recorded using a plain x-ray machine. The IVU is often replaced by the CT scan urogram.

What is a Retrograde Pyelogram? This is a different type of x-ray where the bladder lining, ureters and kidneys are seen during the cystoscopy procedure itself. A special dye is injected using a catheter put in one ureter at a time and a plain x-ray machine is used to take pictures. The difference here is that the dye is manually injected into the ureters and not into the veins.

What is Computed Tomography or CT? The CT scan is commonly used for staging and follow-up. A dye can also be injected into a vein to outline the kidney, both ureters and the bladder. The CT urogram has largely replaced the IVU for follow-up of bladder cancers. Three important pieces of information are obtained for bladder cancer staging using the CT scan. CT scan can demonstrate spread of the tumor beyond the bladder, to nearby lymph nodes of the pelvis and to distant organs, including the liver and lungs. The CT scan involves a slowly rotating camera and an x-ray that take pictures of the body from many angles. An attached computer then combines these pictures into detailed cross-sectional images. Alternately, an MRI scan can be used if a CT cannot be performed.

What is Magnetic Resonance Imaging or MRI? Magnetic resonance imaging applies powerful magnets and radio waves instead of x-rays to take detailed cross-sectional images. The MRI gives information similar to a CT scan. Your doctor will usually order it after the earlier tests remain inconclusive or if you cannot tolerate contrast (dye) due to iodine allergy or poor kidney function. It is more expensive and insurance coverage is often an issue.

What is a Bone Scan? Bone scans are used to detect spread of bladder cancer to the bones which are called bone metastases. Bone scans are used prior to beginning of treatment if you have an aggressive bladder cancer and either bone pain or abnormal alkaline phosphatase blood test.

What is a PET scan? PET is also called “molecular imaging”. PET provides a total-body overview of glucose (sugar) metabolism, which can reveal metabolic changes of cancer before anatomic abnormalities can be detected by conventional imaging, like CT and ultrasound. PET may be used to assess for distant metastases, distinguish malignant from benign masses or detect recurrent tumors that could change your treatment.