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BLADDER CANCER OVERVIEW — Cancer of the urinary bladder is one of the most common cancers. The most common type of bladder cancer in the United States and Western Europe is urothelial cancer, also known as transitional cell carcinoma (TCC).
The optimal treatment for urothelial bladder cancer depends on the cancer's stage and grade:
●Approximately 70 percent of all new cases of bladder cancer are classified as non-muscle invasive, also called superficial bladder cancer. The initial treatment for this stage of bladder cancer is surgical removal of the tumor through a cystoscope, called transurethral resection of bladder tumor (TURBT). This is often followed by adjuvant (additional) therapy, which reduces the chances of the cancer recurring. (See 'Transurethral resection of bladder tumor (TURBT)' below.)
Approximately 20 to 25 percent of initially non-muscle invasive cancers will progress to invasive types during the person's lifetime.
●The remaining 30 percent of bladder cancers are muscle invasive and generally require surgery to remove the bladder (cystectomy) and the surrounding organs. In select situations, chemotherapy may be used. (See "Patient education: Bladder cancer treatment; muscle invasive cancer (Beyond the Basics)".)
This article discusses the treatment of non-muscle invasive bladder cancer. The diagnosis and staging of bladder cancer are discussed separately. (See "Patient education: Bladder cancer diagnosis and staging (Beyond the Basics)".)
CANCER CARE DURING THE COVID-19 PANDEMIC — COVID-19 stands for "coronavirus disease 2019." It is an infection caused by a virus called SARS-CoV-2. The virus first appeared in late 2019 and has since spread throughout the world. Getting vaccinated lowers the risk of severe illness; experts recommend COVID-19 vaccination for anyone with cancer or a history of cancer.
In some cases, if you live in an area with a lot of cases of COVID-19, your doctor might suggest rescheduling or delaying medical appointments. But this decision must be balanced against the importance of getting care to screen for, monitor, and treat cancer. Your doctor can talk to you about whether to make any changes to your appointment schedule. They can also advise you on what to do if you test positive or were exposed to the virus.
INITIAL BLADDER CANCER TREATMENT — The most common first treatment of non-muscle invasive bladder cancer is surgery to remove any abnormal-appearing areas inside the bladder; this is called transurethral resection of bladder tumor (TURBT).
Transurethral resection of bladder tumor (TURBT) — TURBT is a procedure in which a physician uses a cystoscope to see inside the bladder and remove any abnormal-appearing areas. A cystoscope is a long, thin tube that contains a light and a camera.
In most cases, this procedure is done in an operating room under anesthesia. After the procedure, you can usually go home; some people need to keep a catheter in for a few days to drain the urine.
In certain cases, usually in people with more aggressive cancers, a second TURBT will be performed several weeks after the first to be sure that no tumor was missed during the original cystoscopy. If all tumor has been removed after this second TURBT, you will begin adjuvant therapy.
BLUE LIGHT (FLUORESCENT) CYSTOSCOPY — Enhanced visualization of tumors and improved removal can be accomplished with the advent of a cystoscopy procedure using blue light together with a dye that is injected into the bladder at least an hour beforehand. This US Food and Drug Association (FDA)-approved dye and procedure are gradually gaining increased acceptance in the United States, although they have been in use in Europe for over a decade. The main advantage of this approach is a decrease in the rate of recurrence, due to the improved detection of tumors that are not seen under standard white light cystoscopy. This also helps define the margins of the bladder tumor for complete removal. Use of blue light cystoscopy results in a 10 to 15 percent decrease in early tumor recurrences.
A similar technological advance does not require dye at all but, instead, uses filters to block all blue and green light to highlight areas of increased blood vessels, which often feed the tumor. This technique is called narrow band imaging (NBI) and can be done in the office with a flexible cystoscope. While not as rigorously studied as blue light cystoscopy, the results of clinical trials suggest a similar degree of increased tumor detection when compared with standard white light cystoscopy.
ADJUVANT BLADDER CANCER THERAPY — Even after tumor removal with transurethral resection of bladder tumor (TURBT), up to 50 percent of people will have a recurrence of their cancer within 12 months. Because of this high recurrence rate, adjuvant (additional) therapy is usually recommended. The type of adjuvant therapy recommended depends on your risk of recurrence:
●Some people who are at low risk of recurrence will be advised to have a single dose of intravesical chemotherapy at the time of the initial TURBT. This is thought to help prevent floating tumor cells dislodged from the TURBT from seeding and starting new tumors. (See 'Intravesical chemotherapy' below.)
"Intravesical" means that the treatment is put inside of the bladder, usually through a catheter (a flexible tube passed through the urethra, where urine exits). This allows a high concentration of the treatment to be applied directly to the areas where tumor cells could remain, potentially destroying these cells and preventing them from re-emerging in the bladder and forming new tumors.
●Some people who are at intermediate risk of recurrence will be advised to have either a full six-week course of intravesical chemotherapy, most commonly mitomycin, epirubicin, or gemcitabine (see 'Intravesical chemotherapy' below), or intravesical immunotherapy with Bacillus Calmette-Guerin (BCG) (see 'Intravesical Bacillus Calmette-Guerin (BCG)' below). Both kinds of therapy usually involve additional booster treatments for up to one year (maintenance therapy).
●People at high risk of recurrence or worsening will be advised to start intravesical BCG, usually within two to six weeks of the first treatment. This is most commonly followed by additional booster treatments (maintenance therapy) once a complete response is obtained. Some patients are advised to consider bladder removal (cystectomy), especially if the disease is extensive.
The risk of recurrence is discussed separately. (See "Patient education: Bladder cancer diagnosis and staging (Beyond the Basics)".)
Intravesical chemotherapy — Chemotherapy refers to the use of medicines to stop or slow the growth of cancer cells. The most commonly used intravesical chemotherapies for bladder cancer are mitomycin and gemcitabine. These are put inside the bladder in one of two ways:
●One regimen involves giving the chemotherapy once, immediately after TURBT. The solution is left in the bladder for 60 minutes, then is allowed to drain out through a catheter.
●Alternatively, the chemotherapy can be given on a weekly basis for six weeks. With this regimen, the bladder is filled with chemotherapy through a catheter, the solution is left for one to two hours, and then the drug is drained through the catheter.
●Maintenance treatment may be given over one to three years.
Side effects — Chemotherapy that is put inside the bladder, such as mitomycin or gemcitabine, often causes temporary irritation of the bladder, including the need to urinate frequently and urgently and pain with urination. Mitomycin can also cause a skin rash on the palms of the hands, soles of the feet, and genitals. If this rash occurs, treatment with mitomycin is stopped and should not be restarted. Occasionally, cortisone (steroid) therapy is prescribed if the effects are severe and not resolving on their own. A different chemotherapy drug that does not cause a rash (such as gemcitabine), or even BCG, might be substituted in this situation. Rarely, both mitomycin and gemcitabine can cause the bladder to shrink down so that it holds less urine.
Intravesical Bacillus Calmette-Guerin (BCG) — BCG is a type of bacteria that causes tuberculosis in cows. It is commonly used as a treatment for non-muscle invasive bladder cancer, particularly for cancers that have a risk of worsening over time. BCG is believed to work by triggering the body's immune system to destroy any cancer cells that remain in the bladder after TURBT.
BCG is in a liquid solution that is put into the bladder with a catheter. The person then holds the solution in the bladder for two hours before urinating. The treatment is usually given once per week for six weeks, starting approximately two to three weeks after the last TURBT. Further booster (maintenance) treatments can extend the benefits of BCG. (See 'Maintenance Bacillus Calmette-Guerin (BCG)' below.)
Benefits of intravesical Bacillus Calmette-Guerin (BCG) — Intravesical BCG, in combination with TURBT, is the most effective treatment for high-risk non-muscle invasive bladder cancer. BCG therapy can delay tumor growth to a more advanced stage and decrease the need for surgical removal of the bladder at a later time.
Side effects of Bacillus Calmette-Guerin (BCG) — Most people who are treated with intravesical BCG have some side effects; the most common of these include the need to urinate frequently, pain with urination, fever, blood in the urine, and body aches. These symptoms usually begin within two to four hours of treatment and resolve within 48 hours.
Anyone who develops a fever (temperature greater than 100.4ºF or 38ºC) and drenching night sweats 48 hours or more after treatment with BCG should contact their health care provider. These may be signs of less common but more serious side effects, including body-wide infection.
TESTING AFTER INITIAL BLADDER CANCER TREATMENT — Tests are usually performed approximately three months after the start of intravesical treatment, or transurethral resection of bladder tumor (TURBT) for those who did not get intravesical therapy, to be sure that the cancer has not recurred. If there are no signs of recurrence, maintenance Bacillus Calmette-Guerin (BCG) treatment may be recommended. (See 'Maintenance Bacillus Calmette-Guerin (BCG)' below.)
If there are signs of cancer recurrence, any abnormal areas will be biopsied and removed with TURBT. Treatment after TURBT will depend on the tumor's stage at recurrence and the amount of time that has passed since the first course of BCG was given. In general, there are two options: further treatment with weekly intravesical therapy or surgical removal of the bladder (cystectomy). (See "Patient education: Bladder cancer treatment; muscle invasive cancer (Beyond the Basics)".)
Maintenance Bacillus Calmette-Guerin (BCG) — Maintenance intravesical BCG treatment is generally recommended for patients with high-risk non-muscle invasive bladder cancer (see "Patient education: Bladder cancer diagnosis and staging (Beyond the Basics)"). The benefit of maintenance treatment is that it may further delay recurrence and progression of the cancer.
Although the optimal duration of maintenance treatment is debated, several expert groups recommend that it be given for at least one year. Maintenance BCG is typically given once per week for three weeks at 3, 6, and 12 months after the initial BCG treatment. In some cases, maintenance BCG treatment will be recommended for one year for those at intermediate risk of recurrence and for three years for those at higher risk for recurrence.
SURVEILLANCE AFTER BLADDER CANCER TREATMENT — Even in people who are treated appropriately, bladder cancer often recurs. Recurrent cancer can develop anywhere along the urinary tract, including the lining of the kidneys, ureters, prostate, urethra, and bladder. Close follow-up after treatment is required to monitor for recurrence.
Cystoscopy and urine cytology — Repeat cystoscopy and urine cytology testing are recommended for surveillance, beginning three months after treatment ends. If there are no signs of recurrence, cystoscopy and urine testing are usually recommended every three to six months for four years, then once per year. Low-risk patients require less frequent cystoscopy and no urine cytology testing.
If there are signs of recurrent bladder cancer, the next step depends on several factors, including the person's age and underlying medical problems, the tumor's stage and grade at recurrence, previous treatments used, and the amount of time that has passed since the last course of treatment. In general, the options include a second course of intravesical therapy (eg, repeat Bacillus Calmette-Guerin [BCG], gemcitabine and docetaxel [either alone or in combination], BCG/interferon, valrubicin), immunotherapy with pembrolizumab, or surgical removal of the bladder (cystectomy). (See "Patient education: Bladder cancer treatment; muscle invasive cancer (Beyond the Basics)".)
Imaging tests — The upper urinary tract (eg, kidneys, ureters) is lined with the same cells as the bladder. The tumors that develop in the bladder can develop in the upper urinary tract as well. As a result, an imaging test, such as a computed tomography (CT) scan, is recommended before and sometimes after the initial course of treatment. This type of test is usually done every one to two years for patients with higher risk tumors.
CT scanning and other types of imaging tests are described separately. (See "Patient education: Bladder cancer diagnosis and staging (Beyond the Basics)".)
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Bladder cancer (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Bladder cancer treatment; muscle invasive cancer (Beyond the Basics)
Patient education: Bladder cancer diagnosis and staging (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Clinical presentation, diagnosis, and staging of bladder cancer
Epidemiology and risk factors of urothelial (transitional cell) carcinoma of the bladder
Treatment of primary non-muscle invasive urothelial bladder cancer
Management of recurrent or persistent non-muscle invasive bladder cancer
The following organizations also provide reliable health information.
●National Cancer Institute
(https://www.cancer.gov/types/bladder)
●The National Library of Medicine
(https://medlineplus.gov/bladdercancer.html)
●American Society of Clinical Oncology
●Raghavan D, Tuthill K. Bladder Cancer — A Cleveland Clinic Guide for Patients, Cleveland Clinic Press/Kaplan Press, Cleveland 2008.
●American Cancer Society
●Bladder Cancer Advocacy camp network
●Bladder Cancer Canada
(https://bladdercancercanada.org/en/)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Michael O'Donnell, MD, who contributed to earlier versions of this topic review.
