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Bladder Cancer Treatment (PDQ®)

  • Last Modified: 08/13/2014

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Treatment Option Overview for Bladder Cancer

Nonmuscle-invasive Bladder Cancer
Muscle-invasive Bladder Cancer



Nonmuscle-invasive Bladder Cancer

Treatment of nonmuscle-invasive bladder cancers (Ta, Tis, T1) is based on risk stratification. Essentially all patients are initially treated with a transurethral resection (TUR) of the bladder tumor followed by a single immediate instillation of intravesical chemotherapy (mitomycin C is typically used in the United States).[1-7]

Subsequent therapy after the treatment above is based on risk and typically consists of one of the following:[6-9]

  • Surveillance for relapse or recurrence (typically used for tumors with low risk of recurrence or progression).
  • A minimum of 1 year of intravesical treatments with bacillus Calmette-Guérin (BCG) plus surveillance for relapse (typically used for tumors at intermediate or high risk of progression to muscle-invasive disease).
  • Additional intravesical chemotherapy (typically used for tumors with a high risk of recurrence but low risk of progression to muscle-invasive disease).
Muscle-invasive Bladder Cancer

Standard treatment for patients with muscle-invasive bladder cancers whose goal is cure is either neoadjuvant multiagent cisplatin–based chemotherapy followed by radical cystectomy and urinary diversion or radiation therapy with concomitant chemotherapy.[10-13] Other treatment approaches include the following:

  • Radical cystectomy followed by multiagent cisplatin–based chemotherapy.
  • Radical cystectomy without perioperative chemotherapy.[14-16]
  • Radiation therapy without concomitant chemotherapy.[17]
  • Partial cystectomy with or without perioperative chemotherapy.[18]

Many patients newly diagnosed with bladder cancer are candidates for participation in clinical trials.

Reconstructive techniques that fashion low-pressure storage reservoirs from the reconfigured small and large bowel eliminate the need for external drainage devices and, in many patients, allow voiding per urethra. These techniques are designed to improve the quality of life for patients who require cystectomy.[19]

Table 7. Standard Treatment Options for Bladder Cancer
Stage (TNM Staging Criteria)  Standard Treatment Options  
BCG = bacillus Calmette-Guérin; EBRT = external-beam radiation therapy; TUR = transurethral resection.
Stage 0 Bladder CancerTUR with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy
TUR with fulguration
TUR with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by periodic intravesical instillations of BCG
TUR with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by intravesical chemotherapy
Segmental cystectomy (rarely indicated)
Radical cystectomy (in rare, highly selected patients with extensive or refractory superficial high-grade tumors)
Stage I Bladder CancerTUR with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy
TUR with fulguration
TUR with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by periodic intravesical instillations of BCG
TUR with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by intravesical chemotherapy
Segmental cystectomy (rarely indicated)
Radical cystectomy in selected patients with extensive or refractory superficial tumors
Stages II and III Bladder CancerRadical cystectomy
Neoadjuvant combination chemotherapy followed by radical cystectomy
EBRT with or without concomitant chemotherapy
Segmental cystectomy (in selected patients)
TUR with fulguration (in selected patients)
Stage IV Bladder CancerT4b, N0, M0 and any T, N1–N3, M0Chemotherapy alone
Radical cystectomy
Radical cystectomy followed by chemotherapy
Radical cystectomy alone
EBRT with or without concomitant chemotherapy
Urinary diversion or cystectomy for palliation
Any T, any N, M1Chemotherapy alone or as an adjunct to local treatment
EBRT for palliation
Urinary diversion or cystectomy for palliation
Recurrent Bladder CancerCombination chemotherapy
Surgery for new superficial or localized tumors
Palliative therapy
Clinical trials

References
  1. Sylvester RJ, Oosterlinck W, van der Meijden AP: A single immediate postoperative instillation of chemotherapy decreases the risk of recurrence in patients with stage Ta T1 bladder cancer: a meta-analysis of published results of randomized clinical trials. J Urol 171 (6 Pt 1): 2186-90, quiz 2435, 2004.  [PUBMED Abstract]

  2. Mariappan P, Smith G: A surveillance schedule for G1Ta bladder cancer allowing efficient use of check cystoscopy and safe discharge at 5 years based on a 25-year prospective database. J Urol 173 (4): 1108-11, 2005.  [PUBMED Abstract]

  3. Nieder AM, Brausi M, Lamm D, et al.: Management of stage T1 tumors of the bladder: International Consensus Panel. Urology 66 (6 Suppl 1): 108-25, 2005.  [PUBMED Abstract]

  4. Oosterlinck W, Solsona E, Akaza H, et al.: Low-grade Ta (noninvasive) urothelial carcinoma of the bladder. Urology 66 (6 Suppl 1): 75-89, 2005.  [PUBMED Abstract]

  5. Sylvester RJ, van der Meijden A, Witjes JA, et al.: High-grade Ta urothelial carcinoma and carcinoma in situ of the bladder. Urology 66 (6 Suppl 1): 90-107, 2005.  [PUBMED Abstract]

  6. Babjuk M, Oosterlinck W, Sylvester R, et al.: EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder. Eur Urol 54 (2): 303-14, 2008.  [PUBMED Abstract]

  7. Babjuk M, Oosterlinck W, Sylvester R, et al.: EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder, the 2011 update. Eur Urol 59 (6): 997-1008, 2011.  [PUBMED Abstract]

  8. Millán-Rodríguez F, Chéchile-Toniolo G, Salvador-Bayarri J, et al.: Upper urinary tract tumors after primary superficial bladder tumors: prognostic factors and risk groups. J Urol 164 (4): 1183-7, 2000.  [PUBMED Abstract]

  9. Millán-Rodríguez F, Chéchile-Toniolo G, Salvador-Bayarri J, et al.: Multivariate analysis of the prognostic factors of primary superficial bladder cancer. J Urol 163 (1): 73-8, 2000.  [PUBMED Abstract]

  10. Sauer R, Birkenhake S, Kühn R, et al.: Efficacy of radiochemotherapy with platin derivatives compared to radiotherapy alone in organ-sparing treatment of bladder cancer. Int J Radiat Oncol Biol Phys 40 (1): 121-7, 1998.  [PUBMED Abstract]

  11. Advanced Bladder Cancer Meta-analysis Collaboration: Neoadjuvant chemotherapy in invasive bladder cancer: a systematic review and meta-analysis. Lancet 361 (9373): 1927-34, 2003.  [PUBMED Abstract]

  12. Winquist E, Kirchner TS, Segal R, et al.: Neoadjuvant chemotherapy for transitional cell carcinoma of the bladder: a systematic review and meta-analysis. J Urol 171 (2 Pt 1): 561-9, 2004.  [PUBMED Abstract]

  13. James ND, Hussain SA, Hall E, et al.: Radiotherapy with or without chemotherapy in muscle-invasive bladder cancer. N Engl J Med 366 (16): 1477-88, 2012.  [PUBMED Abstract]

  14. Madersbacher S, Hochreiter W, Burkhard F, et al.: Radical cystectomy for bladder cancer today--a homogeneous series without neoadjuvant therapy. J Clin Oncol 21 (4): 690-6, 2003.  [PUBMED Abstract]

  15. Stein JP, Dunn MD, Quek ML, et al.: The orthotopic T pouch ileal neobladder: experience with 209 patients. J Urol 172 (2): 584-7, 2004.  [PUBMED Abstract]

  16. Manoharan M, Ayyathurai R, Soloway MS: Radical cystectomy for urothelial carcinoma of the bladder: an analysis of perioperative and survival outcome. BJU Int 104 (9): 1227-32, 2009.  [PUBMED Abstract]

  17. Widmark A, Flodgren P, Damber JE, et al.: A systematic overview of radiation therapy effects in urinary bladder cancer. Acta Oncol 42 (5-6): 567-81, 2003.  [PUBMED Abstract]

  18. Holzbeierlein JM, Lopez-Corona E, Bochner BH, et al.: Partial cystectomy: a contemporary review of the Memorial Sloan-Kettering Cancer Center experience and recommendations for patient selection. J Urol 172 (3): 878-81, 2004.  [PUBMED Abstract]

  19. Hautmann RE, Miller K, Steiner U, et al.: The ileal neobladder: 6 years of experience with more than 200 patients. J Urol 150 (1): 40-5, 1993.  [PUBMED Abstract]