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Over 75 percent of bladder cancers remain confined to the lining of the bladder and do not invade the bladder wall. These are called nonmuscle-invasive bladder cancer, or superficial bladder cancer, and when managed well, they are associated with excellent prognoses. Muscle-invasive bladder cancer, or advanced bladder cancer, is cancer that has invaded the bladder wall or spread outside of the bladder. These cancers require more aggressive clinical management. Bladder cancer treatment options vary depending on whether the cancer is nonmuscle-invasive or muscle-invasive, and specific treatments are determined based on the stage and grade of the tumor(s).
Cystoscopy is an outpatient procedure during which a thin, lighted tube with a camera is passed through the urethra into the bladder, allowing your doctor to see the inside of the bladder. Most modern cystoscopes are also equipped with channels that permit small instruments to be passed into the bladder. During a cystoscopy, your doctor may use these instruments to remove tissue, stop bleeding with a special electrical device called an electrocautery or even perform laser treatment. If the bladder cancer tumor is small enough, this cautery may be used to remove the cancer. Transurethral Resection of the Bladder Cancer TumorThis is when the tumor is removed from the urinary tract through the urethra using an electrical force. Transurethral resection (TUR) is an endoscopic or scope procedure that does not involve making an incision in the body. Drug therapy after TUR is commonly prescribed for patients with large, multiple or high-grade tumors. Intravesical Drug Therapy (Chemotherapy and Immunotherapy)Intravesical drug therapy involves placing medicines directly into the bladder via a urethral catheter to lower the recurrence rates of bladder tumors. It is usually used for multiple carcinomas in situ that cover a large area (5 centimeters-plus), or for high-grade or high-stage tumors. Commonly used intravesical drugs are:
Understand the basics of bladder cancer, from risk factors and diagnosis to the various treatment and urinary diversion options available. Armine Smith, M.D., a surgeon at the Johns Hopkins Greenberg Bladder Cancer Institute, tells you what you need to know.
When bladder cancer tumors completely invade the bladder’s muscular wall, the standard of care is to perform bladder removal surgery. Typically, complete removal of the bladder (radical cystectomy) is required. Partial cystectomy is rare because the requirements are that the tumor is easily accessible and small in size, and that there are no tumors in the rest of the bladder. This approach is usually used only if the cancer has not left its site of origin. Additionally, partial cystectomy may be an alternative option for nonmuscle-invasive bladder cancer if all other treatments fail. Radiation TherapyRadiation therapy, used to treat cancer, is a special high-energy X-ray that is more powerful than the X-rays used for imaging studies. Radiation therapy is planned and executed in a way to kill cancer cells or alter their ability to reproduce, while the surrounding healthy cells are minimally affected. Historically, radiation therapy alone has been used for muscle-invasive bladder cancer, but current treatment usually involves a combined approach of maximal local surgery, radiation and chemotherapy. The role of radiation therapy in this combined approach is to kill the bladder cancer cells in the bladder that are not visible to the surgeon. Chemotherapy is used to enhance the effects of the radiation and kill cells outside the bladder. Local lymph nodes are frequently radiated as part of the therapy to treat the microscopic cancer cells that may be there. ChemotherapyChemotherapy uses chemical agents to interfere with replication and other normal functions of cells, resulting in tumor shrinkage or cancer cell death. The use of two or more chemotherapy drugs together has been found to be more effective than a single drug alone. There are several types of chemotherapy. The most common chemotherapeutic drug used in bladder cancer is cisplatin. ImmunotherapyImmunotherapy is a cancer treatment approach that uses drugs and vaccines to harness the immune system’s natural ability to fight cancer, in the same way it fights off infections. The approach is still being researched and there is a lot left to learn, but clinical studies have shown that immunotherapy holds a lot of promise in its ability to treat a wide range of malignancies, including some types of bladder cancer. There are a few FDA-approved immunotherapy drugs available for treating advanced and metastatic bladder cancer that has worsened after chemotherapy. Scientists are also investigating the possibility that combinations of immunotherapy drugs could be more effective than individual drugs. Illustration showing inside and outside views of an ileal conduit.
This procedure has been routinely performed since the 1950s. The internal pouch that holds the urine is made from a small portion of intestinal tract. One end is closed with sutures, while the other end is attached to skin on the front side of the abdomen. A stoma is the open end of the conduit attached to the skin. An external appliance (ostomy bag) covers the stoma to collect urine. The ureters are implanted into the back of the ileal conduit. Catheterizable Continent Diversion PouchThis is a reservoir of bowel with a stoma that is catheterizable for emptying the bladder. The urine is siphoned out of the urinary reservoir with a small catheter every four to six hours. The catheterizable pouch may require surgical repair at some point after surgery due to the wear and tear of frequent catheterization. This type of reconstruction is not performed on patients with a history of bowel disease. NeobladderA neobladder is a new bladder made from a section of the patient’s small intestine. This internal, new bladder is connected to the urethra and ureters. After this reconstruction, the patient needs to relearn how to void. Some disadvantages of this type of reconstruction are the possibility of incontinence and scar tissue formation at the connection of the urethra and new bladder.
People with cancer need support and information, no matter what stage of illness they may be in. Knowing all of your options and finding the resources you need will help you make informed decisions about your care. Whether you are thinking about treatment, getting treatment, or not being treated at all, you can still get supportive care to help with pain or other symptoms. Communicating with your cancer care team is important so you understand your diagnosis, what treatment is recommended, and ways to maintain or improve your quality of life. Different types of programs and support services may be helpful, and can be an important part of your care. These might include nursing or social work services, financial aid, nutritional advice, rehab, or spiritual help. The American Cancer Society also has programs and services – including rides to treatment, lodging, and more – to help you get through treatment. Call our National Cancer Information Center at 1-800-227-2345 and speak with one of our trained specialists.
Go to Health Professional Version The bladder is a hollow organ in the lower part of the abdomen. It is shaped like a small balloon and has a muscular wall that allows it to get larger or smaller to store urine made by the kidneys. There are two kidneys, one on each side of the backbone, above the waist. Tiny tubules in the kidneys filter and clean the blood. They take out waste products and make urine. The urine passes from each kidney through a long tube called a ureter into the bladder. The bladder holds the urine until it passes through the urethra and leaves the body. EnlargeAnatomy of the male urinary system (left panel) and female urinary system (right panel) showing the kidneys, ureters, bladder, and urethra. Urine is made in the renal tubules and collects in the renal pelvis of each kidney. The urine flows from the kidneys through the ureters to the bladder. The urine is stored in the bladder until it leaves the body through the urethra.There are three types of bladder cancer that begin in cells in the lining of the bladder. These cancers are named for the type of cells that become malignant (cancerous):
Cancer that is in the lining of the bladder is called superficial bladder cancer. Cancer that has spread through the lining of the bladder and invades the muscle wall of the bladder or has spread to nearby organs and lymph nodes is called invasive bladder cancer. See the following PDQ summaries for more information: Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk to your doctor if you think you may be at risk for bladder cancer. Risk factors for bladder cancer include the following: Older age is a risk factor for most cancers. The chance of getting cancer increases as you get older. These and other signs and symptoms may be caused by bladder cancer or by other conditions. Check with your doctor if you have any of the following:
The following tests and procedures may be used:
The prognosis depends on the following:
If the cancer is superficial, prognosis also depends on the following:
Treatment options depend on the stage of bladder cancer.
The process used to find out if cancer has spread within the bladder lining and muscle or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:
Cancer can spread through tissue, the lymph system, and the blood:
When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.
The metastatic tumor is the same type of cancer as the primary tumor. For example, if bladder cancer spreads to the bone, the cancer cells in the bone are actually bladder cancer cells. The disease is metastatic bladder cancer, not bone cancer. Many cancer deaths are caused when cancer moves from the original tumor and spreads to other tissues and organs. This is called metastatic cancer. This animation shows how cancer cells travel from the place in the body where they first formed to other parts of the body.In stage 0, abnormal cells are found in tissue lining the inside of the bladder. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is divided into stages 0a and 0is, depending on the type of the tumor:
In stage I, cancer has formed and spread to the layer of connective tissue next to the inner lining of the bladder. In stage II, cancer has spread to the layers of muscle tissue of the bladder. Stage III is divided into stages IIIA and IIIB.
Stage IV is divided into stages IVA and IVB.
The cancer may come back in the bladder or in other parts of the body.
Different types of treatment are available for patients with bladder cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment. One of the following types of surgery may be done:
After the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy after surgery to kill any cancer cells that are left. Treatment given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy. Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer. Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). For bladder cancer, regional chemotherapy may be intravesical (put into the bladder through a tube inserted into the urethra). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Combination chemotherapy is treatment using more than one anticancer drug. See Drugs Approved for Bladder Cancer for more information. Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This cancer treatment is a type of biologic therapy. There are different types of immunotherapy:
See Drugs Approved for Bladder Cancer for more information. Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack certain cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do. The following targeted therapies are approved for patients with bladder cancer that is locally advanced or has spread to other parts of the body: Ramucirumab is a type of targeted therapy that is being studied in combination with chemotherapy for the treatment of bladder cancer. It blocks VEGF to help keep new blood vessels from forming. This may keep cancer cells from growing and may kill them. It is a type of angiogenesis inhibitor and a type of monoclonal antibody. Information about clinical trials is available from the NCI website. For information about side effects caused by treatment for cancer, see our Side Effects page. For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment. Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment. Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward. Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment. Clinical trials are taking place in many parts of the country. Information about clinical trials supported by NCI can be found on NCI’s clinical trials search webpage. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website. Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups. Bladder cancer often recurs (comes back), even when the cancer is superficial. Surveillance of the urinary tract to check for recurrence is standard after a diagnosis of bladder cancer. Surveillance is closely watching a patient’s condition but not giving any treatment unless there are changes in test results that show the condition is getting worse. During active surveillance, certain exams and tests are done on a regular schedule. Surveillance may include ureteroscopy and imaging tests. See staging tests, above. Physician Data Query (PDQ) is the National Cancer Institute's (NCI's) comprehensive cancer information database. The PDQ database contains summaries of the latest published information on cancer prevention, detection, genetics, treatment, supportive care, and complementary and alternative medicine. Most summaries come in two versions. The health professional versions have detailed information written in technical language. The patient versions are written in easy-to-understand, nontechnical language. Both versions have cancer information that is accurate and up to date and most versions are also available in Spanish. PDQ is a service of the NCI. The NCI is part of the National Institutes of Health (NIH). NIH is the federal government’s center of biomedical research. The PDQ summaries are based on an independent review of the medical literature. They are not policy statements of the NCI or the NIH. This PDQ cancer information summary has current information about the treatment of bladder cancer. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care. Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Updated") is the date of the most recent change.
The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Adult Treatment Editorial Board.
A clinical trial is a study to answer a scientific question, such as whether one treatment is better than another. Trials are based on past studies and what has been learned in the laboratory. Each trial answers certain scientific questions in order to find new and better ways to help cancer patients. During treatment clinical trials, information is collected about the effects of a new treatment and how well it works. If a clinical trial shows that a new treatment is better than one currently being used, the new treatment may become "standard." Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Clinical trials can be found online at NCI's website. For more information, call the Cancer Information Service (CIS), NCI's contact center, at 1-800-4-CANCER (1-800-422-6237).
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