Patient education: Bladder cancer treatment; non-muscle invasive (superficial) cancer (Beyond the Basics)
- Wassim Kassouf, MD, CM, FRCS
Wassim Kassouf, MD, CM, FRCS
- Professor of Surgery (Urology)
- McGill University Health Center
- Peter Black, MD, FACS, FRCSC
Peter Black, MD, FACS, FRCSC
- Khosrowshahi Chair in Bladder Cancer Research
- Associate Professor
- Department of Urologic Sciences
- University of British Columbia
- Vancouver Prostate Centre
BLADDER CANCER OVERVIEW
The optimal treatment for urothelial bladder cancer depends upon 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 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.)
Of these, 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. (See "Patient education: Bladder cancer treatment; invasive cancer (Beyond the Basics)".)
This article has facts about 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)".)
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 while the person is under anesthesia. After the procedure, you can usually go home, sometimes with a catheter for a few days.
In certain cases, usually in people with more aggressive microinvasive 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 FDA-approved dye and procedure is gradually gaining increased acceptance in the United States, although it has been in use in Europe for over a decade. The main advantage of this approach is a decrease in the rates of recurrence due to the 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 absolute decrease in early tumor recurrences.
A similar technological advance does not require a 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 show a similar degree of increased tumor detection when compared to standard white light cystoscopy.
ADJUVANT BLADDER CANCER THERAPY
Even in people who have their bladder tumor completely removed with transurethral resection of bladder tumor (TURBT), up to 50 percent 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 upon 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 to seed and start 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 reemerging 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 or epirubicin (see 'Intravesical chemotherapy' below), or intravesical immunotherapy with Bacillus Calmette-Guerin (BCG) (see 'Intravesical 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. Occasionally, however, 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 chemotherapy for bladder cancer is mitomycin. This is put inside the bladder in one of two ways:
●One regimen involves giving the mitomycin once, immediately after TURBT. The solution is left in the bladder for 60 minutes, then allowed to drain out through a catheter.
●Alternatively, the mitomycin can be given on a weekly basis for six weeks. With this regimen, the bladder is filled with mitomycin through a catheter, the solution is left for one to two hours, then the drug is drained through the catheter. A maintenance treatment may be given once per month for up to one year.
Side effects — Mitomycin 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 therapy is prescribed if the effects are severe and not resolving on their own. A different chemotherapy drug or even BCG might be substituted in this situation. Rarely, mitomycin can cause the bladder to shrink down so that it holds less urine.
Intravesical BCG — BCG is an attenuated live bacterium that causes cow tuberculosis. It is a common 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 they urinate. 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 benefit of BCG. (See 'Maintenance BCG' below.)
Benefits of intravesical BCG — Intravesical BCG, in combination with TURBT, is the most effective treatment for non-muscle invasive bladder cancer. BCG therapy has been shown to 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 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 bodywide 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 BCG' below.)
If there are signs of cancer recurrence, any abnormal areas will be biopsied and removed with TURBT. Treatment after TURBT will depend upon 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; invasive cancer (Beyond the Basics)".)
Maintenance 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 a 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 three, six, and 12 months after the initial BCG treatment. In some cases, maintenance BCG will be recommended with treatment 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, and 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 upon 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 (repeat Bacillus Calmette-Guerin [BCG], BCG/interferon, valrubicin, or gemcitabine) or surgical removal of the bladder (cystectomy). (See "Patient education: Bladder cancer treatment; 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 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 web site (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.
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.
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
●The National Library of Medicine
●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 (http://www.bcan.org/))
●Bladder Cancer Canada (https://bladdercancercanada.org/en/
- Shelley MD, Court JB, Kynaston H, et al. Intravesical Bacillus Calmette-Guerin in Ta and T1 Bladder Cancer. Cochrane Database Syst Rev 2000; :CD001986.
- Smith JA Jr, Labasky RF, Cockett AT, et al. Bladder cancer clinical guidelines panel summary report on the management of nonmuscle invasive bladder cancer (stages Ta, T1 and TIS). The American Urological Association. J Urol 1999; 162:1697.
- Sylvester RJ, van der MEIJDEN AP, Lamm DL. Intravesical bacillus Calmette-Guerin reduces the risk of progression in patients with superficial bladder cancer: a meta-analysis of the published results of randomized clinical trials. J Urol 2002; 168:1964.
- Mariappan P, Smith G, Lamb AD, et al. Pattern of recurrence changes in noninvasive bladder tumors observed during 2 decades. J Urol 2007; 177:867.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.