If you or a loved one have been diagnosed with bladder cancer, you undoubtedly have many questions about what comes next. The best treatment for each person depends on the type of bladder cancer, their overall health and personal priorities, so your doctor will discuss an individual treatment plan. Here, you can review key topics and common questions about cancer treatment, plus find reliable information to explore these topics in more detail.

Who treats bladder cancer?

The initial referral from a family doctor will generally be to a urologist for diagnostic investigations and bladder surgery if required. Women may see a urogynecologist. In some cases, bladder cancer is diagnosed after an emergency room visit. Medical and radiation oncologists may also be involved in treatment, along with specialist nurses and a supporting team with varied expertise, such as nutritionists and social workers.

How is bladder cancer treated?

Treatment for bladder cancer depends on the tumor characteristics and the disease stage, which identifies whether the tumor is superficial (only in the bladder lining) or invasive (growing into the underlying connective tissue or muscle layers), and whether it has spread beyond the bladder. Depending on the stage and grade of disease most patients will have surgery, often followed by radiation therapy and medical treatment (such as BCG and/or chemotherapy drugs).

Treatment may be local (treating just the bladder) or systemic (whole body):

  • Local therapy means that medicine is delivered directly into the bladder via a catheter – this is called intravesical treatment. Intravesical chemotherapy or immunotherapy can lower the risk of cancer returning.
  • Systemic therapy is used to kill cancer cells that may have spread beyond the bladder. Chemotherapy, targeted therapy, and immunotherapy can all be given systemically, either intravenously (IV) or taken as a capsule or pill.

Several new treatments for bladder cancer such as immune checkpoint inhibitors and targeted therapies have become available in recent years.

Bladder cancer surgery

The two main types of bladder cancer surgery to know about are transurethral resection of bladder tumor (TURBT) and cystectomy (bladder removal surgery). For more information on bladder cancer surgery, including side effects, the American Cancer Society has a useful overview of surgery.

TURBT surgery

TURBT is the most common type of surgery for early bladder cancer. It is used to obtain a tumor sample for diagnosis and staging, and as a first treatment to remove superficial tumors that have not penetrated beyond the bladder lining. TURBT is done through the urethra using a modified cystoscope with a small wire loop which can have an electric current run through it. It is done under anesthesia (spinal or general). If the tumor is small and you have no other medical problems, you will likely go home the same day. Otherwise, an overnight stay with a catheter in place may be needed.

Bladder removal surgery

About 75% of newly diagnosed patients have non-muscle-invasive bladder cancer.1 However, in cases where the tumor has grown into the muscle layer of the bladder, surgery to remove all or part of the bladder (cystectomy) may be recommended, followed by reconstructive surgery to divert urine flow. Although this is a major operation suitable for patients in good overall health, most people who undergo the surgery adapt well to their ‘new normal’ and can lead full and active lives. Some patients may choose not to have a cystectomy and instead discuss alternative treatments with their doctor. The Mayo Clinic has helpful information on cystectomy and advice and support is available (see Patient resources).

Types of chemotherapy for bladder cancer

Intravesical chemotherapy

Intravesical chemotherapy is used to treat early bladder cancer, often with a single treatment immediately after TURBT to kill any cancer cells remaining after removal of visible disease. Urinary symptoms like bladder irritation are common after intravesical treatment but, overall, side effects are much reduced compared with systemic chemotherapy.

Systemic chemotherapy

Systemic chemotherapy is often given before surgery (neoadjuvant therapy) to shrink a tumor and reduce the risk of recurrence. It can also be given after surgery to kill any remaining cancer cells (adjuvant therapy), combined with radiation therapy, or given as the main treatment for bladder cancer that has spread into other areas of the body (metastatic disease).

Radiation therapy

Radiotherapy uses high-energy waves to kill cancer cells. In early bladder cancer, radiotherapy may be administered after TURBT. Chemotherapy can increase the effectiveness of radiation and may be given at the same time, for example to try to avoid cystectomy. Radiotherapy can also relieve cancer symptoms in patients with advanced disease.

Immunotherapy: BCG and checkpoint inhibitors

Immunotherapy helps the body’s immune system recognize and attack cancer cells.

BCG treatment for bladder cancer

Bacillus Calmette-Guerin (BCG) is a weakened form of the bacterium that causes tuberculosis (TB) and was originally used for TB vaccination. Intravesical BCG is used after TURBT to treat patients with superficial disease who have risk factors for the cancer returning or progressing. Optimally, patients receive an initial course of BCG (typically once a week for 6 weeks) then intermittent BCG treatments for at least 1 year. Flu-like symptoms and bladder discomfort are common side effects.

Immune checkpoint inhibitors

Immune checkpoint inhibitors help to restore the immune response against cancer cells and are a major development in treatment, but only about 20% of bladder cancer patients will benefit.2 The U.S. Food and Drug Administration (FDA) has approved several checkpoint inhibitors known as programmed cell death protein-1 (PD-1) or PD-L1 inhibitors, which block binding of the PD-L1 protein on tumor cells to the PD-1 receptor on immune T cells. They are approved to treat specific groups of patients with advanced urothelial cancer.

New treatments for bladder cancer: targeted therapy

Targeted therapies are designed to target features of cancer cells that differ from healthy cells, such as gene alterations or cell-surface proteins. Targeted therapies with FDA approval to treat advanced bladder cancer after previous therapies have stopped working include:

  • a drug targeting the fibroblast growth factor receptor (FGFR), for patients with mutations in the FGFR3 or FGFR2 gene3,4
  • antibody-drug conjugates (ADCs), where an antibody attaches to a target protein, releasing a cytotoxic drug that kills the cancer cell. 5

Treatment of bladder cancer by stage

At diagnosis, a disease stage from 0 to 4 is assigned by combining information on the tumor (T), lymph nodes (N) and any metastasis (M); stage 0 is superficial cancer and stage 4 means cancer has spread to other parts of the body.6 Stage 2 or higher indicates muscle-invasive bladder cancer, an important consideration for treatment. Also important is the tumor grade: high-grade tumors are more aggressive, meaning the cancer is more likely to grow and to recur after treatment.

Treatment for early-stage bladder cancer (stages 0–1)

  • Patients with low-grade, superficial bladder cancer may only require TURBT with a single dose of intravesical chemotherapy and ongoing follow-up to detect any new tumors.
  • However, most patients with non-muscle invasive bladder cancer receive multiple doses of intravesical chemotherapy or BCG, beginning a few weeks after TURBT and often continuing for a year or more. BCG is preferred for patients at higher risk of recurrence.

Treatment for invasive and advanced bladder cancer

  • Patients with bladder cancer that has grown into (stage 2) or beyond the bladder wall (stage 3) but has not spread beyond the pelvic region may be recommended to undergo cystectomy, with systemic chemotherapy given first as this can improve survival. Alternatively, patients may have TURBT followed by chemotherapy plus radiation to try to preserve the bladder.7
  • For patients with metastatic (stage 4) bladder cancer (where cancer has progressed beyond the bladder), systemic chemotherapy is usually the first treatment. If chemotherapy stops working, subsequent treatments may include immunotherapy and targeted therapy, to try to slow disease progression and extend survival.

Is bladder cancer curable?

The likely outcome after treatment depends on the disease stage, the tumor type, and non-disease factors such as the patient’s age and health. As with most cancers, outcomes are best if the cancer is detected early. Superficial bladder cancer is highly treatable, but many patients develop new tumors even after successful treatment, so regular monitoring is important to enable early detection and further treatment as required. For information on the average survival for patients with different stages of bladder cancer, see Bladder cancer survival - the importance of early detection.

Making bladder cancer treatment decisions

  • Deciding on a course of treatment may feel daunting. Take time to understand your diagnosis, prognosis, and the risks and benefits of each treatment option.
  • The American Society of Clinical Oncology (ASCO) recommends that anyone diagnosed with muscle-invasive bladder cancer talk through their options with a urologist, a medical oncologist, and a radiation oncologist.8 While a doctor may recommend a particular treatment, people have different priorities when considering the importance of preserving the bladder or sexual function versus life expectancy, so shared decision making is important.
  • For metastatic cancer, medical oncologists will have experience with the different treatments, but opinion varies as to the best approach. You may wish to get a second opinion, and to ask each doctor how they interpreted your test results and arrived at their treatment plan. Discussing your eligibility for any available clinical trials may be another option to consider.
  • You can also do your own research on current treatment guidelines, which have patient versions available. Connecting with others who have been through the same experience may be very helpful (see Patient resources).

Treating bladder cancer in elderly patients

Bladder cancer increases with age, in fact over 40% of new cases are aged ≥75 years (see figure).9 Elderly patients do not always receive the most effective treatments, yet those in good general health have similar outcomes to younger individuals, except for a higher risk from surgery.

Advanced age alone is not a reason to withhold treatment that could improve survival or quality of life. Factors to consider include whether an elderly person is living independently, frailty, risk of falls, existing medical conditions and medications. For frail individuals, the treatment intensity may be reduced.

After treatment: remission and the risk of bladder cancer recurrence

People who have been treated for bladder cancer have unique monitoring needs due to the high risk of recurrence, even when diagnosed early. Doctors generally recommend a cystoscopy to examine the inside of the bladder and urethra every 3 to 12 months, depending on risk factors, for several years after bladder cancer treatment. If several years of surveillance have gone by and no cancer recurrence has been detected, a yearly cystoscopy may be enough, depending on the nature and severity of the original cancer.

Cxbladder is a non-invasive surveillance alternative

Cxbladder is a non-invasive genomic urine test that quickly and accurately detects or rules out bladder cancer. The test combines clinical risk factor markers with genetic information, measuring five biomarker genes to detect the presence or absence of bladder cancer. Cxbladder Monitor - one of several tests in the Cxbladder suite - is an accurate and clinically proven surveillance alternative designed to rule out the return of bladder cancer. The test provides reliable results with a single urine sample, reducing the need for frequent cystoscopies which can be both uncomfortable and inconvenient.

Cxbladder is trusted by over 1,800 US urologists in more than 40,000 patients. The test comes with the option of in-home sampling and is covered by Medicare.
Learn more about Cxbladder     Ask us a question

 

Useful resources for patients with bladder cancer

  • Patient education and support: the Bladder Cancer Advocacy Network (BCAN) provides educational resources and support services, including on-line and phone support to connect with survivors . Check out their “Get The Facts” series for practical information and tips from patients on what to expect from treatment.
  • Treatment overview: see the Article sources below for useful website links; the American Cancer Society’s guide to treating bladder cancer can also be downloaded as a PDF file. Bladder Cancer Canada offers patient-friendly treatment guides and the American Urological Association also has guides to non-muscle invasive and muscle-invasive bladder cancer on the Urology Care Foundation website.
  • Talking to your doctor: suggested questions for your medical team from the American Cancer Society [link]; a helpful Australian site has downloadable lists of questions for surgeons, oncologists and radiation oncologists [link - bottom of page].
  • Drug information: National Cancer Institute list of FDA-approved drugs for bladder cancer (including immunotherapy and targeted therapy) [link]; Cancer drug information resources [link]
  • Side effects: American Cancer Society’s guide to dealing with treatment side effects [link] (not specific to bladder cancer)
  • Bladder removal surgery: BCAN explains cystectomy and urinary reconstruction options, with practical tips from patients as well as expert webinars and video stories. A helpful guide for patients facing cystectomy can be downloaded from Bladder Cancer Canada [link], while the Cancer Council in Australia has very useful information on managing changes after treatment, especially for patients adjusting to life with a urinary diversion.

 

References

  1. American Urological Association (AUA) and Society of Urologic Oncology (SUO). Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Joint Guideline (2020).
  2. Eisenstein M. Therapeutics: Spoilt for choice. Nature 2017;551:S36–S38.
  3. Loriot Y, et al.; BLC2001 Study Group. Erdafitinib in locally advanced or metastatic urothelial carcinoma. N Engl J Med. 2019;381(4):338-348. doi:10.1056/NEJMoa1817323. PMID: 31340094.
  4. Montazeri K, Bellmunt J. Erdafitinib for the treatment of metastatic bladder cancer. Expert Rev Clin Pharmacol. 2020;13:1-6. doi:10.1080/17512433.2020.1702025. PMID: 31810398.
  5. Bin Riaz I, Singh P. Antibody-Drug Conjugates for Treatment of Urothelial Carcinoma.
  6. American Society of Clinical Oncology. Bladder Cancer: Stages and Grades.
  7. Bladder Cancer Advocacy Network. Bladder Preservation with Combined Modality Therapy: An Expert Explanation by Dr. William Shipley. [PDF file]
  8. American Society of Clinical Oncology. Bladder Cancer: Treatments by Stage.
  9. National Cancer Institute Surveillance, Epidemiology, and End Results Program (SEER). SEER Cancer Stat Facts: Bladder Cancer.

Article Sources

Overview of bladder cancer treatment

Types of treatment for bladder cancer

Treatment of bladder cancer by disease stage

Making treatment decisions

Elderly patients and bladder cancer treatment

Last Updated: 12 Apr 2022 01:36 pm

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