Treatment of Bladder Cancer by Stage
Most of the time, treatment of bladder cancer is based on the tumor’s clinical stage when it's first diagnosed. Stage means how deep it's thought to have grown into the bladder wall and whether it has spread beyond the bladder. Other factors, such as the size of the tumor, how fast the cancer cells are growing (grade ), and a person’s overall health and preferences, also affect treatment options.
Treating stage 0 bladder cancer
Stage 0 bladder cancer includes non-invasive papillary carcinoma (Ta) and flat non-invasive carcinoma (Tis or carcinoma in situ). In either case, the cancer is only in the inner lining layer of the bladder. It has not invaded (spread deeper into) the bladder wall.
Sometimes no further treatment is needed. Cystoscopy is then done every 3 to 6 months to watch for signs that the cancer has come back.
For low-grade (slow-growing) non-invasive papillary (Ta) tumors, weekly intravesical chemotherapy may be started a few weeks after surgery. If the cancer comes back, the treatments can be repeated. Sometimes intravesical chemo is repeated over the next year to try to keep the cancer from coming back.
High-grade (fast-growing) non-invasive papillary (Ta) tumors are more likely to come back after treatment, so intravesical Bacille-Calmette Guerin (BCG) is often used after surgery. Before it's given, TURBT is commonly repeated to be sure the cancer has not affected the muscle layer. BCG is usually started a few weeks after surgery and is given every week for several weeks. Intravesical BCG seems to be better than intravesical chemotherapy for high-grade cancers. It can help both keep these cancers from coming back and keep them from getting worse. But it also tends to have more side effects. It, too, may be be done for the next year or so.
Stage 0 bladder cancers rarely need to be treated with more extensive surgery. Partial or complete cystectomy (removal of the bladder) is considered only when there are many superficial cancers or when cancer continues to grow (or seems to be spreading) despite treatment.
For flat non-invasive (Tis) tumors, BCG is the treatment of choice after TURBT. Patients with these tumors often get 6 weekly treatments of intravesical BCG, starting a few weeks after TURBT. Some doctors recommend repeating BCG treatment every 3 to 6 months.
Follow-up and outlook after treatment
After treatment for any stage 0 cancer, close follow-up is needed, with cystoscopy about every 3 months for a least a couple of years to look for signs of the cancer coming back or new bladder tumors.
The outlook for people with stage 0a (non-invasive papillary) bladder cancer is very good. These cancers can be cured with treatment. During long-term follow-up care, more superficial cancers are often found in the bladder or in other parts of 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 as good as for stage 0a cancers. These cancers have a higher risk of coming back, and may return as a more serious cancer that's growing into deeper layers of the bladder or has spread to other tissues.
Treating stage I bladder cancer
Stage I bladder cancers have grown into the connective tissue layer of the bladder wall (T1), but have not reached the muscle layer.
Transurethral resection (TURBT) with fulguration is usually the first treatment for these cancers. But it's done to help determine the extent of the cancer rather than to try to cure it. If no other treatment is given, many people will later get a new bladder cancer, which often will be more advanced. This is more likely to happen if the first cancer is high-grade (fast-growing).
Even if the cancer is found to be low grade (slow-growing), a second TURBT is often recommended several weeks later. If the doctor then feels that all of the cancer has been removed, intravesical BCG (preferred) or intravesical chemo is usually given. (Less often, close follow-up alone might be an option.) If all of the cancer wasn't removed, options are 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's first found, radical cystectomy may be recommended.
Treating stage II bladder cancer
These cancers have invaded the muscle layer of the bladder wall (T2a and T2b), but no farther. Transurethral resection (TURBT) is the first treatment for these cancers, but it's done to help determine the extent (stage) of the cancer rather than to try to cure it.
When the cancer has invaded the muscle, radical cystectomy (removal of the bladder) is the standard treatment. Lymph nodes near the bladder are often removed as well. If cancer is in only one part of the bladder, a partial cystectomy may be done instead. But this is possible in only a small number of patients.
Radical cystectomy may be the only treatment for people who are not well enough to get chemo. But most doctors prefer to give chemo before surgery because it's 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 chemo shrinks the bladder cancer, but it might be harmful if the tumor continues to grow during chemo.
If cancer is found in nearby lymph nodes, radiation may be needed after surgery. Another option is chemo, but only if it wasn't given before surgery.
Certain people may be able to have a second (and more extensive) transurethral resection (TURBT), followed by radiation and chemotherapy. While this lets patients keep their bladder, 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, frequent and careful follow-up exams are needed. Some experts recommend a repeat cystoscopy and biopsy be done during the chemo and radiation treatment. If cancer is still found in the biopsy sample, a cystectomy will likely be needed.
For patients who can’t have surgery because of other serious health problems, TURBT, radiation, chemotherapy, or some combination of these may be options.
Treating stage III bladder cancer
These cancers have reached the outside of the bladder (T3) and might have grown into nearby tissues or organs (T4) and/or lymph nodes (N1, N2, or N3). They have not spread to distant parts of the body.
Transurethral resection (TURBT) is often done first to find out how far the cancer has grown into the bladder wall. Chemotherapy followed by radical cystectomy (removal of the bladder and nearby lymph nodes) is then the standard treatment. Partial cystectomy is rarely an option for stage III cancers.
Chemotherapy (chemo) before surgery (with or without radiation) can shrink the tumor, which may make surgery easier. Chemo can also kill any cancer cells that could already have spread to other areas of the body and help people live longer. It can be especially useful for T4 tumors, which have spread outside the bladder. When chemo is given first, surgery to remove the bladder is delayed. The delay is not a problem if the chemo shrinks the cancer, but it can be harmful if it continues to grow during chemo. Sometimes the chemo shrinks the tumor enough that intravesical therapy or chemo with radiation is possible instead of surgery.
Some patients get chemo after surgery to kill any cancer cells left after surgery that are too small to see. Chemo given after cystectomy may help patients stay cancer-free longer, but so far it’s not clear if it helps them live longer. If cancer is found in nearby lymph nodes, radiation may be needed after surgery. Another option is chemo, but only if it wasn't given before surgery.
An option for some patients with single, small tumors (some T3) might be treatment with a second (and more extensive) transurethral resection (TURBT) followed by a combination of chemo and radiation. If cancer is still found when cystoscopy is repeated, cystectomy might be needed.
For patients who can’t have surgery because of other serious health problems, treatment options might include TURBT, intravesical therapy, radiation, chemotherapy, immunotherapy, or some combination of these.
Treating stage IV bladder cancer
These cancers have reached the abdominal or pelvic or abdominal wall (T4b), may have spread to nearby lymph nodes (any N), and/or have spread to distant parts of the body (M1). Stage IV cancers are very hard to get rid of completely.
Chemotherapy (with or without radiation) is usually the first treatment if the cancer has not spread to distant parts of the body (M0). The tumor is then rechecked. If it appears to be gone, chemo with or without radiation or cystectomy are options. If there are still signs of cancer in the bladder, chemo with or without radiation, changing to another kind of chemo, adding an immunotherapy drug, or cystectomy may be recommended.
Chemo with or without radiation is the first treatment when bladder cancer has spread to distant parts of the body (M1). After this treatment the cancer is rechecked. If it looks like it's gone, a boost of radiation to the bladder may be given or cystectomy might be done. If there are still signs of cancer, chemo, radiation, both at the same time, and immunotherapy might be options.
In most cases surgery (even radical cystectomy) can’t remove all of the cancer, so treatment is usually aimed at slowing the cancer’s growth and spread to help people live longer and feel better. If surgery is a treatment option, it's important to understand the goal of the operation – is it to try to cure the cancer, help a person live longer, or help prevent or relieve symptoms from the cancer?
People who can’t tolerate chemo because of other health problems might be treated with radiation therapy or with an immunotherapy drug. Urinary diversion without cystectomy is sometimes done to prevent or relieve a blockage of urine that could cause severe kidney damage.
Because treatment is unlikely to cure these cancers, many experts recommend taking part in a clinical trial.
Treating bladder cancer that progresses or recurs
If cancer continues to grow during treatment (progresses) or comes back after treatment (recurs), treatment options will depend on where and how much the cancer has spread, what treatments have already been used, and the patient's overall health and desire for more treatment. It’s important to understand the goal of any further treatment – if it’s to try to cure the cancer, to slow its growth, or to help relieve symptoms – as well as the likely benefits and risks.
For instance, non-invasive bladder cancer often comes back in the bladder. The new cancer may be found either in the same place as the original cancer or in other parts of the bladder. These tumors are often treated the same way as the first tumor. But if the cancer keeps coming back, a cystectomy (removal of the bladder) may be needed.
Cancers that recur in distant parts of the body can be harder to remove with surgery and other treatments, such as chemotherapy, immunotherapy, or radiation therapy, might be needed. For more on dealing with a recurrence, see our section called Understanding Recurrence.
At some point, it may become clear that standard treatments are no longer controlling the cancer. If the patient wants to continue getting treatment, taking part in a clinical trial of newer bladder cancer treatments might be recommended. While these are not always the best option for every person, they can benefit current, as well as future patients.
American Society of Clinical Oncology. Bladder Cancer: Treatments by Stage. 10/2017. Accessed at www.cancer.net/cancer-types/bladder-cancer/treatments-stage on January 25, 2019.
DeGeorge KC, Holt HR, Hodges SC. Bladder Cancer: Diagnosis and Treatment. Am Fam Physician. 2017;96(8):507-514.
National Cancer Institute. Bladder Cancer Treatment (PDQ®)–Health Professional Version. November 16, 2018. Accessed at www.cancer.gov/types/bladder/hp/bladder-treatment-pdq on January 25, 2019.
National Cancer Institute. Bladder Cancer Treatment (PDQ®)–Patient Version. October 19, 2018. Accessed at www.cancer.gov/types/bladder/patient/bladder-treatment-pdq on January 25, 2019.
National Comprehensive Cancer Network, Clinical Practice Guidelines in Oncology (NCCN Guidelines®), Bladder Cancer, Version 5.2018 -- July 3, 2018. Accessed at www.nccn.org/professionals/physician_gls/pdf/bladder.pdf on January 25, 2019.
Information provided by American Cancer Society.