Staging is the process of gathering information from exams and diagnostic tests to determine how widespread a cancer is. The stage of a cancer is important when deciding the best treatment. The stage can also help predict the patient's prognosis (outlook).

The findings at surgery as well as the results of previous biopsies are used to see how far the cancer has spread. Doctors examining the biopsy sample are especially interested in noting if any cancer cells have spread into the bladder's muscle layers.

A staging system is a standard way to describe the extent of cancer spread. The staging system most often used for bladder cancer is that of the American Joint Committee on Cancer (AJCC). This is also called the TNM system.

The letter T is followed by a number from 1 to 4 to describe how far the tumors has grown through the bladder wall and into nearby tissues. Higher T numbers mean more extensive growth.

The letter N is followed by a number from 0 to 3 to indicate any cancer spread to lymph nodes near the bladder. Lymph nodes are normally bean-sized collections of immune system cells that help fight infections and cancers.

The letter M is followed by 0 or 1 to indicate whether or not the cancer has spread to distant sites (such as other organs or lymph nodes that are not near the bladder).

Once a patient's T, N, and M categories have been determined, this information is combined in a process called stage grouping to find the cancer stage. Bladder cancer stages range from the number 0 to the Roman numeral IV. Stage 0 is the earliest and least serious stage, while Stage IV is the most advanced and serious.

The next section explains some features of the 2002 version of AJCC (American Joint Committee on Cancer) staging for bladder cancer. It includes details of specific T, N, and M categories and how they are grouped to determine a bladder cancer's stage.

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. If you have bladder cancer, ask your cancer care team to explain its stage. In this way, you will be able to make informed choices about your treatment.

TNM staging of bladder cancer

There are actually 2 types of staging for bladder cancer:

• The clinical stage is based on the results of tests, biopsies, and surgery done to remove the tumor through the cystoscope.

• The pathologic stage is based on the results of surgery to remove the bladder and nearby lymph nodes.

The clinical stage is used to help plan treatment. Sometimes, though, the cancer has spread further than the clinical stage estimates. Because the pathological stage is based on what was found at surgery, it more accurately predicts the patient’s outlook for survival.

T: bladder tumor categories

Bladder cancer can affect many areas of the bladder at the same time. If multiple cancers are found, the letter m is added to the appropriate T category.

When nonpapillary bladder cancer is found in the very superficial lining of the bladder but is not growing into surrounding tissues, it is called carcinoma in situ (CIS).

Ta: Noninvasive papillary carcinoma
Tis: Carcinoma in situ (CIS); noninvasive flat carcinoma
T1: The tumor has grown below the urothelial lining but not as deep as the muscle tissue
T2: The tumor has grown into the muscle layer

T3: The tumor has grown outside the bladder into the fatty tissue that surrounds the bladder

T4: The tumor has spread to beyond the fatty tissue. It is growing into any of the following: prostate, uterus, vagina, pelvic wall, or abdominal wall

T4a: The tumor has spread to the prostate, uterus, and/or vagina
T4b: The tumor has spread to the pelvic wall or the abdominal wall

N: regional lymph node categories

This category only describes the lymph nodes near the bladder (the regional lymph nodes). These are the lymph nodes that are in the true pelvis. Any other lymph nodes are considered distant lymph nodes (the M category is used for spread to distant nodes). Surgery is usually needed to find cancer spread to lymph nodes, since it is not often seen on imaging studies.

NX: Regional lymph nodes cannot be assessed due to lack of information
N0: No regional lymph node spread
N1: The cancer has spread to a single lymph node that is 2 cm (4/5 inch) or smaller
N2: Either:

• The cancer has spread to a single lymph node that is larger than 2 cm but not larger than 5 cm (2 inches); or
• The cancer has spread to 2 or more lymph nodes, none of which is larger than 5 cm

N3: The cancer has spread to a lymph node that is larger than 5 cm

M: distant spread (metastasis) categories

Stages of bladder cancer

Stage 0a (Ta, N0, M0):

The cancer is a noninvasive papillary carcinoma. It has grown toward the hollow center of the bladder but has not grown into the muscle or connective tissue of the bladder wall. It has not spread to lymph nodes or distant sites.

Stage 0is (Tis, N0, M0):

The cancer is a flat, noninvasive carcinoma, also known as flat carcinoma in situ (CIS). The cancer is growing in the lining layer of the bladder only. It has neither grown inward toward the hollow part of the bladder nor has it invaded the muscle or connective tissue of the bladder wall. It has not spread to lymph nodes or distant sites.

Stage I (T1, N0, M0):

The cancer has grown into the layer of connective tissue under the lining layer of the bladder without growing into the thick layer of muscle in the bladder wall. The cancer has not spread to lymph nodes or to distant sites.

Stage II (T2, N0, M0):

The cancer has grown into the thick muscle layer of the bladder wall but, it has not passed completely through the muscle to reach the layer of fatty tissue that surrounds the bladder. The cancer has not spread to lymph nodes or to distant sites.

Stage III (T3 or T4a, N0, M0):

The cancer has grown completely through the bladder into the layer of fatty tissue that surrounds the bladder (T3). It may have spread into the prostate, uterus, or vagina (T4a). It is not growing into the pelvic or abdominal wall. The cancer has not spread to lymph nodes or to distant sites.

Stage IV (T4b, N0, M0) or (any T, N 1 to 3, M0) or (any T, any N, M1):

The cancer has spread through the bladder wall to the pelvic or abdominal wall (T4b) and/or has spread to lymph nodes (N1-3) and/or to distant sites such as bones, liver, or lungs (M1)

Survival rates by stage

The numbers below are based on patients diagnosed from 1988 to 2001. These numbers come from the National Cancer Institute, SEER Data Base.

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Five-year rates are used to produce a standard way of discussing prognosis. Of course, many people live much longer than 5 years. Five-year relative survival rates assume that people will die of other causes and compare the observed survival with that expected for people without bladder cancer. This gives a better picture of the deaths from bladder cancer.

Last Medical Review: 01/27/2009
Last Revised: 5/13/2009