Most of the time, initial treatment of bladder cancer is based on the tumor's clinical stage – its size, how deep it has grown into the bladder wall, and whether it has spread beyond the bladder. This is based on the results of exams, cystoscopy, and imaging tests.
Stage 0
Stage 0 bladder cancer includes non-invasive papillary carcinoma (Ta) and flat non-invasive carcinoma (Tis). In either case, the cancer has not invaded the bladder wall beyond the inner layer.
This early stage of bladder cancer is most often treated with transurethral resection (TUR). This may be followed either by observation (without further treatment) or by intravesical therapy to try to keep the cancer from coming back.
In the United States, doctors prescribe intravesical BCG more often than intravesical chemotherapy after TUR. Of these treatments, BCG seems to be better at both keeping cancers from coming back and from getting worse. But it also tends to have more side effects. For this reason, doctors usually reserve BCG for cancers that are more likely to come back as invasive cancer or spread within the bladder, such as high-grade cancers or flat non-invasive carcinomas. Patients with these tumors often get 6 weekly treatments of intravesical BCG, starting at least 2 weeks after TUR. The bladder may be checked again about 6 weeks after the last treatment to look for signs of cancer. Some doctors recommend repeating BCG treatment every 3 to 6 months. BCG treatment reduces the recurrence rate by at least half.
Some doctors prefer to give intravesical chemotherapy after surgery (instead of BCG). Intravesical chemotherapy is more often used in patients with low-grade, non-invasive tumors. This treatment is usually given every week for several weeks. If the cancer comes back, the treatments can be repeated. Low-grade papillary tumors are less likely to come back in a more serious form. Patients with these tumors may receive a single dose of intravesical mitomycin right after surgery.
Stage 0 bladder cancer rarely needs to be treated with partial or radical cystectomy. Cystectomy is considered only when there are many superficial cancers or when a superficial cancer continues to grow (or seems to be spreading) despite treatment.
The outlook for people with stage 0a (non-invasive papillary) bladder cancer is excellent. These cancers are nearly always cured with the right treatment. During long-term follow-up care, more superficial cancers are often found in the bladder or elsewhere in the urinary system. Although these new cancers do need to be treated, they rarely are deeply invasive or life threatening.
The long-term prognosis for stage 0is bladder cancer (also known flat non-invasive cancer) is not quite as good. These cancers have a higher risk of coming back, and may return as a more serious cancer, one that is growing into deeper layers of the bladder or has spread to other tissues.
Stage I
Stage I bladder cancers have grown into the connective tissue layer of the bladder wall but have not reached the muscle layer.
These cancers are often treated like stage 0 cancers, with transurethral resection (TUR) followed by intravesical therapy with BCG or chemotherapy. However, over half of these patients later get a new bladder cancer. In many cases, the new cancer will invade the bladder muscle and be a higher stage. This is more likely to happen if the first cancer is high grade. If this happens, radical cystectomy may be needed.
If the cancer is high-grade, if many tumors are present, or if the tumor is extremely large, even when it is first found, radical cystectomy may be recommended as the initial treatment. This is done to try to keep the cancer from coming back and spreading elsewhere. Another option for some high-grade tumors may be transurethral resection (TUR) followed by a combination of chemotherapy and radiation.
For people who can't have a cystectomy, radiation therapy (often along with chemo) may be an option as the main treatment, although the chances for cure may not be as good.
Stage II
These cancers have invaded the muscle layer of the bladder wall. Radical cystectomy is the standard treatment for these cancers. Lymph nodes near the bladder are often removed as well. Some patients with cancer in only one part of the bladder can be treated with a partial cystectomy instead, but only a small number of patients are good candidates for this.
Although at this stage cancer cells have not been detected outside the bladder, in some cases there may already be tiny deposits of cancer growing elsewhere in the body. These tiny deposits, called micrometastases, are too small to see on imaging tests but may eventually grow to become life threatening. This risk is greater with more deeply invasive cancers and higher-grade cancers. For this reason, chemotherapy is often given either before surgery (neoadjuvant chemo) or after surgery (adjuvant chemo) to lower the chance the cancer will come back in a distant site. It is not clear which is better. Each has its advantages.
Another option may be transurethral resection (TUR), followed by radiation and chemotherapy. This approach is only used when there is a single, small tumor with no CIS on biopsy and the tumor is blocking urine flow from a kidney. If the cancer comes back and cannot be controlled by local treatment, cystectomy can still be done. If this treatment is used you will need frequent and careful follow-up exams. Some experts recommend a repeat cystoscopy with biopsy during treatment with chemo and radiation. If cancer is found on the biopsy, cystectomy will be needed.
For patients who cannot have a major operation because of other serious medical conditions, TUR, radiation, or chemotherapy may be used as the only treatment. If the patient is well enough, chemotherapy may be given along with radiation therapy to help it work better.
Stage III
These cancers have reached the outside of the bladder and may have grown into nearby tissues or organs. Stage III cancers are treated much in the same way as stage II tumors. Radical cystectomy, with removal of nearby lymph nodes, is the standard treatment for stage III bladder cancer. Partial cystectomy is seldom an option for stage III cancers.
Chemotherapy is often given before surgery. This is called neoadjuvant therapy and it can shrink the tumor, which may make surgery easier. This can be especially useful for T4a tumors. The chemotherapy may also kill any cancer cells that may already have spread to other areas of the body. This approach has been shown to help patients live longer than cystectomy alone. When chemotherapy is given first, surgery to remove the bladder is delayed. The delay is not a problem if the chemotherapy causes the bladder cancer to shrink, but it can be harmful if the tumor continues to grow during chemotherapy.
Some patients get chemotherapy after surgery, which is called adjuvant treatment. It is meant to kill any cancer cells that remain after surgery but are too small to see. Chemotherapy given only after cystectomy may help patients stay cancer-free longer, but so far it's not clear if it helps them live longer.
Some patients with T3a cancers can be treated with a transurethral resection (TUR) of the tumor followed by a combination of chemotherapy and radiation. If this isn't successful and cancer is found when cystoscopy is repeated, then the patient may need cystectomy. This bladder-sparing approach is not an option if the bladder has more than one tumor, if CIS is present, or if the tumor is blocking urine flow from a kidney.
For patients who cannot have a major operation because of other serious medical conditions, TUR, radiation, or chemotherapy may be used as the only treatment. If the patient is well enough, chemotherapy may be given along with radiation therapy to help it work better.
Stage IV
These cancers have reached the abdominal or pelvic wall (T4b tumors) or have spread to nearby lymph nodes or distant parts of the body.
In most cases surgery (even radical cystectomy) cannot remove all of the cancer at this stage, so these cancers are very hard to treat successfully. Treatment is usually aimed at slowing the cancer's growth and spread to help you live longer and feel better. If your doctor discusses surgery as treatment option, be sure you understand the goal of the operation – whether it is to try to cure the cancer, to help you live longer, or to help prevent or relieve symptoms from the cancer – before deciding on treatment.
For stage IV bladder cancers that have not spread to distant sites, chemotherapy (with or without radiation) is usually the first treatment. If the cancer shrinks in response to treatment, a cystectomy may be an option. Patients who can't tolerate chemotherapy (because of other health problems) are often treated with radiation therapy.
For stage IV bladder cancers with distant spread, chemotherapy is usually the first treatment, sometimes along with radical cystectomy or radiation therapy. Patients who can't tolerate chemotherapy (because of other health problems) are often treated with radiation therapy. Urinary diversion without cystectomy is sometimes done to prevent or relieve a blockage of urine that could otherwise cause severe kidney damage.
Because treatment is unlikely to cure these cancers, taking part in a clinical trial may offer you access to newer forms of treatment that might help you live longer or relieve symptoms.
Recurrent bladder cancer
When a cancer comes back after treatment, it is called recurrent. Recurrence can be local (in or near the place it started) or distant (spread to organs such as the lungs or bone). The outlook and treatment of recurrent bladder cancer depends on the location and extent of the recurrent cancer and the type of prior treatment. If cancer continues to grow during treatment or comes back, further treatment will depend on the extent of the cancer, what treatments have been used, and a person's health and desire for further treatment.
For example, non-invasive bladder cancers often recur locally in the bladder. The new cancer may be found either in the same site as the original cancer or at other sites in the bladder. These tumors are often treated the same way as the first tumor. But if the tumor keeps coming back, then the patient may need a cystectomy at some point.
Cancers that recur in distant sites can be harder to remove with surgery and may require other treatments, such as chemotherapy or radiation therapy.
At some point, it may become clear that standard treatments are no longer controlling the cancer. If you want to continue anti-cancer treatment, you might think about taking part in a clinical trial of newer bladder cancer treatments. While these are not always the best option for every person, they may benefit you as well as future patients.
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