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 superficial or early bladder cancer. T2 and T3 are classed as invasive bladder cancer. T4 is called advanced bladder cancer.
Grade
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. High grade cancers tend to grow more quickly and are more likely to spread. On the full version of this page, there are details of a new grading system for early bladder cancer that has been developed by the World Health Organisation.
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.
The TNM system is a quick and detailed way of writing down the stage of a cancer accurately. There is more about the TNM cancer stages in our about cancer section.
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 'superficial bladder cancer' or 'non muscle invasive 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.
- Grade 1 cancers have cells that look very like normal cells - they are called 'low grade' or 'well differentiated' and tend to grow slowly and are not likely to spread
- Grade 2 cancers have cells that look more abnormal - they are called 'medium grade' or 'moderately differentiated' and may grow or spread more quickly than low grade
- Grade 3 cancers have cells that look very abnormal - they are called 'high grade' or 'poorly differentiated' and are more quickly growing and more likely to spread
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) - 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 or MRI scan.
- CIS - very early, high grade, cancer cells are detected 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 or vagina
- T4b - the cancer has spread to the wall of the pelvis or abdomen
There are four lymph node stages in bladder cancer. These relate to lymph nodes in the pelvis (the lower part of your tummy, inside your hip bones). The lymph nodes can be seen and measured on a CT 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 - one affected lymph node smaller than 2cm across
- N2 - one affected lymph node larger than 2cm, but smaller than 5cm. Or more than one node affected, but all of them smaller than 5cm across
- N3 - at least one affected lymph node larger than 5cm across
The size of the lymph nodes is used in staging because the more cancer cells there are growing in a node, the larger it will be.
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 more information in the CancerHelp UK sections on treating invasive bladder cancer and treating advanced bladder cancer.
As with most cancers, there are two 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 the bones, lungs or liver. If your cancer has spread, you have advanced bladder cancer. Look at the CancerHelp UK 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), 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 innermost layer of the bladder - in the lining. In some people, they 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 is called Tis in the TNM staging for bladder cancer. Carcinoma in situ 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.
There is detailed information about treatment for early bladder cancer in the treating bladder cancer section of CancerHelp UK.
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. CancerHelp UK has 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 local 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 more information.
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