Bladder Cancer

Nonmuscle-invasive bladder cancers should be completely removed by transurethral resection or fulguration. Immediate postoperative instillation of chemotherapeutic agents (mitomycin-C and gemcitabine) has been shown to reduce recurrences. Repeated outpatient bladder instillations may also reduce recurrences. Carcinoma in situ and other high-grade nonmuscle-invasive urothelial carcinomas are treated with bacille Calmette-Guérin (BCG) instillation after transurethral resection (1 Treatment reference Bladder cancer is usually transitional cell (urothelial) carcinoma. Patients usually present with hematuria (most commonly) or irritative voiding symptoms such as frequency and/or urgency; later... read more ). Instillation can be done at intervals from weekly to monthly over 1 to 3 years. In patients who cannot tolerate BCG or in whom the bladder cancers recur or progress, options include intravesical chemotherapy (gemcitabine/docetaxel), IV pembrolizumab, early cystectomy, and clinical trial enrollment.

Tumors that penetrate the muscle (ie, ≥ stage T2) usually require radical cystectomy (removal of bladder and adjacent structures) with concomitant urinary diversion; partial cystectomy is possible for < 5% of patients. Neoadjuvant chemotherapy with a cisplatin-containing regimen prior to cystectomy is considered standard of care in eligible patients. Lymphadenectomy at the time of surgery is required for staging and potential therapeutic benefit; however, the extent is debatable.

Urinary diversion following cystectomy traditionally involves routing urine through an ileal conduit to an abdominal stoma and collecting it in an external drainage bag. Alternatives such as orthotopic neobladder or continent cutaneous diversion are becoming common and are appropriate for many patients. For both procedures, an internal reservoir is constructed from the intestine. For the orthotopic neobladder, the reservoir is connected to the urethra. Patients empty the reservoir by relaxing the pelvic floor muscles and increasing abdominal pressure, so that urine passes through the urethra almost naturally. Most patients maintain urinary control during the day, but some incontinence may occur at night. For continent cutaneous urinary diversion, the reservoir is connected to a continent abdominal stoma. Patients empty the reservoir by self-catheterization at regular intervals throughout the day.

Bladder-preservation protocols that combine chemotherapy and radiation therapy may be appropriate for a subset of patients, including those who are older or those who refuse more aggressive surgery. These protocols may provide 5-year survival rates of 36 to 74% with 10 to 20% of patients requiring salvage cystectomy.

Patients should be monitored every 3 to 6 months for progression or recurrence.

Metastases require chemotherapy, generally cisplatin based, which is frequently effective but rarely curative unless metastases are confined to lymph nodes. This can be followed by maintenance immunotherapy with avelumab. Combination chemotherapy may prolong life in patients with metastatic disease. For patients who are cisplatin ineligible or have progressed after receiving cisplatin-based regimens, newer immunotherapies using PD-1 and PD-L1 inhibitors are available, such as pembrolizumab and atezolizumab. The first targeted therapy, erdafitinib, is now available for use in patients with FGFR3 and FGFR2 mutations who have failed treatment with chemotherapy.

Treatment of recurrent cancer depends on clinical stage and site of recurrence and previous treatment. Recurrence after transurethral resection of superficial tumors is usually treated with a 2nd resection or fulguration. Early cystectomy is recommended for recurrent high-grade superficial bladder cancers.