Bladder Cancer

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Treating Bladder Cancer TOPICS

Treatment of bladder cancer by stage

Most of the time, initial treatment of bladder cancer is based on the tumor’s clinical stage, which is how deep it is thought to have grown into the bladder wall and whether it has spread beyond the bladder. Other factors, such as the size and grade of the tumor, may also affect treatment options. All of these are 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 (close follow-up without further treatment) or by intravesical therapy to try to keep the cancer from coming back.

Of the intravesical treatments, Bacille-Calmette Guerin (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.

Stage 0a: For low-grade non-invasive papillary (Ta) tumors, the options after TUR include observation, a single dose of intravesical chemotherapy (usually mitomycin) within a day of surgery, or weekly intravesical chemo, starting a few weeks after surgery. If the cancer comes back, the treatments can be repeated.

High-grade non-invasive papillary (Ta) tumors are more likely to come back after treatment, so intravesical BCG is often recommended after surgery. Another option is intravesical chemotherapy with mitomycin. As with BCG, this is usually started several weeks after surgery and is given every week for several weeks. A third option is close observation without intravesical treatment.

Stage 0is: For flat non-invasive (Tis) tumors, BCG is the treatment of choice after surgery. Patients with these tumors often get 6 weekly treatments of intravesical BCG, starting a few weeks after TUR. Some doctors recommend repeating BCG treatment every 3 to 6 months. BCG treatment reduces the recurrence rate by at least half.

Stage 0 bladder cancers rarely need 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.

Following treatment for any stage 0 cancer, close follow-up is recommended, with cystoscopy about every 3 to 6 months for a least a couple of years to look for signs of the cancer coming back or for new bladder tumors.

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 outlook for stage 0is (flat non-invasive) bladder cancer is not quite as good as for stage 0a cancers. 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.

Transurethral resection (TUR) is typically the initial treatment for these cancers. 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.

Even if the cancer is found to be low grade, a second TUR may be recommended several weeks later. If the doctor feels that all of the cancer has been removed, intravesical BCG or mitomycin is given. If the doctor was not able to remove all of the cancer, options include either intravesical BCG or cystectomy (removal of part or all of the bladder).

If the cancer is high grade, if many tumors are present, or if the tumor is very large when it is first found, radical cystectomy may be recommended. This is done to try to keep the cancer from coming back and spreading elsewhere. Another option for some high-grade tumors may be a repeat transurethral resection (TUR) followed by intravesical BCG.

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. Transurethral resection (TUR) is typically the first treatment for these cancers, but it is done to help determine the extent of the cancer rather than to try to cure it.

When the cancer has invaded the muscle, radical cystectomy is the standard treatment. Lymph nodes near the bladder are often removed as well. If cancer is in only one part of the bladder, some patients can be treated with a partial cystectomy instead. 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, called micrometastases, growing elsewhere in the body. These are too small to see on imaging tests but may eventually grow and 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.

Many doctors prefer to give chemo before surgery because it has been shown to help patients live longer than surgery alone. When chemo is given first, surgery is delayed. This is not a problem if the chemotherapy causes the bladder cancer to shrink, but it might be harmful if the tumor continues to grow during chemotherapy.

Another option for some patients may be transurethral resection (TUR), followed by radiation and chemotherapy. Some people may prefer this because it lets them keep their bladder, but it’s not clear if the outcomes are as good as they are after cystectomy, so not all doctors agree with this approach. If this treatment is used you will need frequent and careful follow-up exams. Some experts recommend a repeat cystoscopy and biopsy during treatment with chemo and radiation. If cancer is found in the biopsy sample, a cystectomy will likely 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 might have grown into nearby tissues or organs.

Transurethral resection (TUR) is typically done first to help determine the extent of the cancer. Radical cystectomy and removal of nearby lymph nodes is then the standard treatment. Partial cystectomy is seldom an option for stage III cancers.

Neoadjuvant chemotherapy is often given before surgery. It can shrink the tumor, which may make surgery easier. This can be especially useful for T4a tumors, which have grown outside the bladder. The chemotherapy may also kill any cancer cells that could already have spread to other areas of the body. This approach helps 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 (adjuvant treatment) to kill any areas of cancer cells left after surgery that are too small to see. Chemotherapy given 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 single, small T3a tumors 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, the patient might need cystectomy.

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 get rid of completely. Treatment is usually aimed at slowing the cancer’s growth and spread to help you live longer and feel better. If you and your doctor discuss 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 might 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 that have spread to distant areas, 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, 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. For more information on recurrence, see our document When Cancer Comes Back: Cancer Recurrence.

At some point, it may become clear that standard treatments are no longer controlling the cancer. If you want to continue getting 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.

Last Medical Review: 02/26/2014
Last Revised: 02/25/2015