Bladder cancer stage and grade
This page tells you about the stages and grading of bladder cancer. You can go straight to information about
What is staging?
Cancers are divided into stages, depending on how far they have grown. The staging system normally used in bladder cancer is called TNM, which stands for tumour, node, metastasis. So TNM staging takes into account how deeply the tumour has grown into the bladder, whether there is cancer in the lymph nodes, and whether cancer has spread to other parts of the body (metastasis).
The T stages of bladder cancer
Cancer that is only in the innermost lining of the bladder is classed as carcinoma in situ (CIS or Tis), or Ta. Cancer that has grown further into the bladder has a T number from 1 to 4. In T1, the cancer has started to grow into the connective tissue just under the bladder lining. In T4, it has spread outside the bladder. T2 and T3 are in between.
Ta, T1 and CIS tumours are classed as non muscle invasive (superficial) or early bladder cancer. T2 and T3 are classed as invasive bladder cancer. T4 is called advanced bladder cancer.
You may hear doctors talk about the grade of your cancer. This means how well developed the cells look under the microscope. In low grade cancers, the cells look very like normal cells and tend to grow slowly and stay within the bladder lining. High grade cancers tend to grow more quickly and are more likely to come back after treatment (recur) or to spread into the muscle layer of the bladder (progress).
You can view and print the quick guides for all the pages in the Treating bladder cancer section.
The stage of a cancer tells the doctor how big the cancer is and whether it has spread. The tests and scans you have when diagnosing your cancer give some information about the stage. It is important because treatment is often decided according to the stage of a cancer. There are different ways of staging cancers. The most common is the TNM system and is used for all cancers.
TNM stands for tumour, node, metastasis. So this staging system takes into account how deeply the tumour has grown into the bladder (T), whether there is cancer in the lymph nodes (N) and whether the cancer has spread to any other part of the body (M). If the cancer has spread it is called metastasis, or metastatic bladder cancer.
Another way of staging cancers is number staging. This is not used much for bladder cancer. There are usually 4 main stages. Stage 1 is the earliest cancer and stage 4 the most advanced. With bladder cancer, it is more usual to refer to early bladder cancer, invasive bladder cancer and advanced bladder cancer. Early bladder cancer is also called non muscle invasive bladder cancer or superficial bladder cancer.
Your doctor may talk to you about the grade of your cancer. This means how well developed the cells look under the microscope.
- Low grade cancers have cells that look very like normal cells – they are called low grade or well differentiated and tend to grow slowly and to stay in the lining of the bladder
- Medium grade cancers have cells that look more abnormal – they are called moderately differentiated and are more likely to spread into the muscle of the bladder (progress) or to come back after treatment
- High grade cancers have cells that look very abnormal – they are called high grade or poorly differentiated, are quickly growing, more likely to come back after treatment and more likely to spread into the bladder muscle (progress)
If you have early bladder cancer, grade is one thing that your doctor may take into account when deciding your treatment. If the cells are high grade, you are more likely to need further treatment to stop the cancer coming back after your specialist has removed it. Carcinoma in situ tumours of the bladder are high grade.
In 2004 the World Health Organisation developed a new grading system for early bladder cancer, which is increasingly being used. This system divides bladder cancers into the following groups
- Urothelial papilloma – non cancerous (benign) tumour
- Papillary urothelial neoplasm of low malignant potential (PUNLMP) – very slow growing and unlikely to spread
- Low grade papillary urothelial carcinoma – slow growing and unlikely to spread
- High grade papillary urothelial carcinoma – more quickly growing and more likely to spread
The T part of TNM tells you how far into the bladder the cancer cells have grown. Doctors find the T stage by a combination of looking at the grade of the cancer cells after a biopsy, examination of the bladder under anaesthetic, and a CT scan or MRI scan.
- CIS (also called Tis) – very early, high grade, cancer cells are only in the innermost layer of the bladder lining
- Ta – the cancer is just in the innermost layer of the bladder lining
- T1 – the cancer has started to grow into the connective tissue beneath the bladder lining
- T2 – the cancer has grown through the connective tissue into the muscle
- T2a – the cancer has grown into the superficial muscle
- T2b – the cancer has grown into the deeper muscle
- T3 – the cancer has grown through the muscle into the fat layer
- T3a – the cancer in the fat layer can only be seen under a microscope (microscopic invasion)
- T3b – the cancer in the fat layer can be seen on tests, or felt by your doctor during an examination under anaesthetic (macroscopic invasion)
- T4 – the cancer has spread outside the bladder
- T4a – the cancer has spread to the prostate, womb (uterus) or vagina
- T4b – the cancer has spread to the wall of the pelvis or abdomen
There are 4 lymph node stages in bladder cancer. The lymph nodes can be seen and measured on a CT scan or MRI scan, or may be found if you need surgery to remove your bladder.
The N stages are
- N0 – no cancer in any lymph nodes
- N1 – there is cancer in one lymph node in the pelvis (the lower part of your tummy, between your hip bones)
- N2 – there is cancer in more than one lymph node in the pelvis
- N3 – there is cancer in one or more lymph nodes just outside the pelvis
It is also possible for bladder cancer to spread to lymph nodes in the abdomen (above the pelvic area) or to lymph nodes in the neck.
If you have cancer in any lymph nodes, your doctor may want you to have chemotherapy treatment before surgery. You can find information about chemotherapy in the sections on treating invasive bladder cancer and treating advanced bladder cancer.
As with most cancers, there are 2 stages for cancer spread or metastases. Either the cancer has spread to another body organ (M1) or it hasn't (M0). If bladder cancer does spread to another part of the body, it is most likely to go to distant lymph nodes, the bones, lungs or liver. If your cancer has spread, you have advanced bladder cancer. Look at the section on treating advanced bladder cancer for more information.
Early bladder cancer is also called superficial bladder cancer or non muscle invasive bladder cancer. This includes carcinoma in situ (CIS or Tis), Ta tumours, and T1 tumours. These are all cancers that have been found very early in their development. The cancer cells are only in the lining, the innermost layer of the bladder. In some people, these cancer cells cause no more trouble after your specialist has removed them and given chemotherapy treatment into the bladder. Higher grade tumours or CIS are more likely to come back after surgery and may need further treatment.
CIS (also called Tis) in the TNM staging for bladder cancer stands for carcinoma in situ. It is a cancer of the flat transitional cells that make up all the moist tissues that line the body organs. It is always high grade. It can be in more than one place in the bladder lining and can look like areas of moss under the microscope. Ta and T1 tumours often look like small mushrooms growing out of the bladder wall.
If you have stage T2 or T3 bladder cancer, this is called invasive bladder cancer. In T2, the cancer has spread into (or invaded) the muscle layer of the bladder. In T3, the cancer has grown through the muscle layer. There is a higher risk that the cancer could spread to other areas of the body than with early bladder cancer. There is a section with detailed information about treating invasive bladder cancer.
Advanced bladder cancer includes T4 bladder cancer, cancer in the lymph nodes, or cancer that has spread to another part of the body. If the cancer has only spread into nearby tissues in the area around the bladder, or to nearby lymph nodes, it is called local spread. Your specialist may treat you as if you had T2 or T3 invasive bladder cancer.
Advanced bladder cancer can be cancer that has come back (recurrence). There is a section on treating advanced bladder cancer with detailed information.
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