Most of the time, initial treatment of bladder cancer is based on the tumor's clinical stage -- its size and how deep it has grown into the bladder wall. Cancer in nearby lymph nodes is hard to see on imaging tests - surgery is the best way to find lymph node spread.

Stage 0

Stage 0 bladder cancer includes noninvasive papillary carcinoma (Ta) and flat noninvasive carcinoma (Tis). This early stage of bladder cancer is most often treated with transurethral resection (TUR). This may be followed by intravesical therapy.

In the United States, doctors prescribe intravesical BCG more often than intravesical chemotherapy after TUR to keep the cancer from coming back. Of these 2 treatments, BCG seems to be better at both keeping certain cancers from coming back and from getting worse. However, since it also tends to have more side effects, doctors use BCG for cancers (like flat noninvasive carcinomas) that are more likely to come back as invasive cancer or spread within the bladder. Patients with these tumors are often treated with 6 weekly treatments of intravesical BCG. Then, 6 weeks after the last treatment, the bladder may be checked again 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 50%.

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. Low-grade (grade I) 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 C after surgery. This treatment is usually given every week for several weeks. If the cancer comes back, the treatments can be repeated.

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 0, Ta bladder cancer is excellent. Noninvasive papillary 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 CIS bladder cancer (also known flat non-invasive cancer) is not quite as good. This cancer has a higher risk of coming back, often returning 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 are treated like stage 0 cancers, with transurethral resection 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. Cystectomy may be recommended if the cancer is high-grade or if many tumors are present. This is done to keep the cancer from coming back and spreading elsewhere. Another approach for high-grade tumors would be bladder sparing surgery with a combination of chemotherapy and radiation.

Stage II

Radical cystectomy is the standard treatment for stage II bladder cancer. Lymph nodes near the bladder are often removed as well. Some patients can be treated with a partial cystectomy, but patients must be carefully evaluated before this choice is made.

Although cancer at this stage shows no recognizable spread beyond 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. Often chemotherapy is given either before surgery (neoadjuvant) or after (adjuvant) 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 is 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. 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.

In rare instances, TUR alone can cure a stage II bladder cancer. Most experts recommend repeating the TUR 4 weeks after the first one to be sure that all of the cancer was removed.

For patients who cannot have a major operation because of other serious medical conditions, radiation may be used as the only treatment. If the patient is well enough, chemo may be given at the same time to help the radiation work better.

Stage III

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. Radiation, with or without chemo, may be used instead of radical cystectomy for patients who cannot have a major operation because of other serious medical conditions. Partial cystectomy is seldom an option for patients with stage III bladder cancer.

Another approach is to give chemotherapy (with or without radiation) before surgery. This is called neoadjuvant therapy and it can shrink the tumor, making surgery easier. This can be especially useful for T4a tumors. The chemo also can 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 chemo is given first, surgery to remove the bladder is delayed. This is not a problem when the chemo causes the bladder cancer to shrink. The delay can be harmful if the tumor continues to grow during chemo. Patients whose cancers keep growing have poorer outcomes.

Some patients get chemo both before and after surgery. When chemo (or radiation) is given after surgery, it 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 doesn't seem to help them live longer.

Some patients with T3a cancers can be treated with an approach that spares the bladder. This involves a transurethral resection 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. A 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.

Stage IV

This stage cannot be cured. Treatment is aimed at slowing the cancer's growth and spread, to help you live longer and feel better. Stage IV bladder cancers that have not spread to distant sites can be treated with chemotherapy (with or without radiation). If the cancer shrinks in response to treatment, a cystectomy may be done. Patients who can't tolerate chemotherapy (from other health problems) are often treated with external beam radiation therapy.

For stage IV bladder cancers with distant spread, options include radical cystectomy, external beam radiation therapy, and systemic chemotherapy, given alone or along with these other treatments. Urinary diversion without cystectomy is sometimes done to relieve a blockage of urine that could otherwise cause severe kidney damage.

Participation in clinical trials of new chemotherapy combinations or new biological therapies can offer access to treatments that may relieve symptoms or help patients to live longer.

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). Outlook and treatment of recurrent bladder cancer depends on the location and extent of the recurrent cancer and the type of prior treatment.

For example, it is not uncommon for noninvasive bladder cancers to 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 evaluated and 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 may require other treatment, such as chemotherapy or radiation therapy.

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