Bladder Cancer

Treatment Planning

Advances in treatment strategies offer promise for people with bladder cancer and their loved ones. Through clinical trials, new and more effective options designed to treat and cure bladder cancer are becoming available. As you and your doctor discuss a treatment plan, make it a priority to share your expectations for your quality of life.

Flexibility and patience will become very important, especially if how you urinate changes. Learn as much as you can about the available options and practical ways to manage them. Talk with other bladder cancer survivors about their experiences. Hearing how someone has managed something similar can help you adopt a positive attitude and move forward more confidently. Use the resources in the back of this guide, and ask your medical team for additional referrals.

Treatment Options

To determine your treatment plan, your doctor considers the tumor’s stage, grade and biomarker status; whether the cancer is non-muscle invasive or muscle-invasive; potential side effects; your general health; and your preferences concerning urine control.

Treatments can be used alone or in combination, and at different times. First-line therapy is the first treatment used. Second-line therapy is given when the first-line therapy does not work or is no longer effective. Standard of care refers to the most widely recommended treatments for the type and stage of cancer you have. Local treatments are directed at a specific organ or a limited area of the body and include surgery and radiation therapy. Systemic treatments are typically drug therapies, such as chemotherapy, immunotherapy and targeted therapy, which travel throughout the body.

Your treatment options may include the following.

Surgery is the primary method for treating a solid tumor. Removing it may offer the best chance of controlling the disease and keeping it from spreading, especially for early-stage disease. Surgery may also be used to stage the cancer or to relieve or prevent symptoms that occur later. A lymph node dissection may also be necessary to stage the cancer or to control cancer that is known to have spread to the nodes. Your doctor may elect to use one or more of the following procedures:

  • Transurethral resection of bladder tumor (TURBT). A surgeon inserts a cystoscope through the urethra into the bladder and removes the tumor using an instrument with a small wire loop, a laser or high-energy electricity. TURBT may be used to diagnose, stage and treat bladder cancer.
  • Cystectomy. A radical cystectomy removes the entire bladder and may also include nearby tissues or organs. Lymph nodes in the pelvis are also removed. In addition, men may have their prostate and urethra removed, and women may have their uterus, fallopian tubes, ovaries and part of the vagina removed. A partial (segmental) cystectomy may be performed to remove only a portion of the bladder, preserving the ability to urinate normally. In some cases, a cystectomy may be done laparoscopically or robotically. 
  • Urinary diversion. If your bladder is removed, another way to store and pass urine is necessary. You and your treatment team will determine which of the three types of diversion will work best for you. 
    • An ileal conduit involves creating a new tube from a piece of intestine (ileum) to allow your kidneys to drain and exit through a small opening called a stoma.
    • A continent cutaneous pouch is a pouch inside your body made from a segment of your intestine that is attached to your ureters, allowing urine to be stored internally and then removed through a hole in your abdomen.
    • A continent cutaneous pouch is a pouch inside your body made from a segment of your intestine that is attached to your ureters, allowing urine to be stored internally and then removed through a hole in your abdomen.

Drug therapy may include chemotherapy, immunotherapy or targeted therapy. Drug therapy may be used alone or combined with other types of treatment.

Chemotherapy uses drugs to kill rapidly multiplying cells throughout the body. Chemotherapy may be used before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy).

To treat bladder cancer, chemotherapy is given intravesically or systemically.

  • Intravesical (local) chemotherapy delivers drugs into the bladder through a catheter inserted through the urethra. Local treatment only destroys superficial tumor cells that come in contact with the chemotherapy solution. It cannot reach tumor cells that have invaded the muscular layer of the bladder wall or tumor cells that have spread to other organs. 
  • Systemic chemotherapy is given intravenously (IV) through a small tube inserted into a vein or port (see Figure 1). It travels through the bloodstream.

Immunotherapy stimulates the immune system to find and attack cancer cells. Types of immunotherapy approved to treat bladder cancer include cytokines, immune checkpoint inhibitors, monoclonal antibodies (mAbs) and modified bacteria.

Cytokines aid in immune cell communication and play an important role in the full activation of an immune response. They are given intravesically.

Immune checkpoint inhibitors prevent the immune system from slowing down, allowing it to keep up its fight against the cancer. They are given intravenously. The immune checkpoint inhibitors approved for bladder cancer are mAbs. The mAbs are laboratory-made antibodies designed to target specific tumor antigens, which are certain proteins or other molecules on the surface of tumor cells that may trigger an immune response.

Modified bacteria, such as bacillus Calmette-Guérin (BCG), have been changed to reduce the likelihood that they will cause a harmful infection while stimulating an immune response. This therapy is given intravesically over multiple weeks (see Figure 2).

Targeted therapy uses drugs to identify and attack cancer cells. The types approved for bladder cancer include a kinase inhibitor and monoclonal antibodies (mAbs).

A kinase inhibitor may be used to treat some bladder cancers with a fibroblast growth factor receptor (FGFR2 or FGFR3) gene mutation. Data suggest that tumors with mutated FGFR3 are less likely to be recognized by the immune system, making targeted therapy an option for this gene mutation.

The approved mAbs are antibody drug conjugates (ADCs). ADCs consist of a mAb that is chemically linked to a chemotherapy drug.

Chemoradiation therapy combines systemic chemotherapy and pelvic radiation therapy. It may be given after the bladder tumor is removed (using TURBT) or instead of surgery. This treatment approach is considered a bladder-preservation option because removal of the bladder may not be necessary if cancer is not detected after treatment. This therapy may be used for tumors that appear to have been completely removed by TURBT, invaded no deeper than the muscle wall and have not obstructed the ureter.

Radiation therapy uses high-energy radiation to destroy cancer cells and shrink tumors. It may be given with chemotherapy to relieve symptoms or to treat advanced disease. External-beam radiation therapy (EBRT) uses a machine outside the body to send radiation toward the cancer.

Clinical trials are medical research studies that may offer access to leading-edge treatments not yet widely available. Researchers are evaluating improved ways of diagnosing and treating bladder cancer, including improving how cystectomies and lymph node dissections are performed, identifying changes to genes or proteins that may lead to bladder cancer, and finding new types of drugs and drug combinations.

Let your team know whether you are open to considering a clinical trial. You can also search on your own. Once you find a potential trial, talk with your doctor.

Recurrent Bladder Cancer

Bladder cancer that returns after treatment is called recurrent bladder cancer. The cancer may return in the same area as the primary cancer or in a different area of the body. It can happen weeks, months or even years after treatment stops, which is why a follow-up care regimen is so important.

If your bladder cancer returns, your doctor will recommend a series of tests to determine any changes in your type of cancer, whether it has spread and physical symptoms. A new treatment plan may be developed, and you may add finding a clinical trial to your plan.

Terms to Know

You will hear many new words and phrases. These definitions will help.

First-line therapy: The first treatment used.

Second-line therapy: Given when the first-line therapy does not work or is no longer effective.

Standard of care: The best treatment known for the type and stage of cancer you have.

Local treatments: Directed to a specific organ or limited area of the body and includes surgery and radiation therapy.

Systemic treatments: Typically drug therapies such as chemotherapy, immunotherapy and targeted therapy that travel throughout the body.

Intravesical therapy: A type of drug therapy that is injected directly into the bladder.

Commonly Used Medications 
doxorubicin (Adriamycin)
mitomycin (Jelmyto, Mitozytrex, Mutamycin)
thiotepa (Tepadina)
valrubicin (Valstar)
interferon (Roferon-A, Intron A, Alferon)
   Immune Checkpoint Inhibitors
atezolizumab (Tecentriq)
avelumab (Bavencio)
nivolumab (Opdivo)
pembrolizumab (Keytruda)
   Modified Bacteria
bacillus Calmette-Guérin (BCG)
Targeted Therapy
   Kinase Inhibitor
erdafitinib (Balversa)
   Monoclonal Antibody
enfortumab vedotin-ejfv (Padcev)
sacituzumab govitecan-hziy (Trodelvy)
Some Possible Combinations
carboplatin (Paraplatin) and gemcitabine (Gemzar)
cisplatin and gemcitabine (Gemzar)
Dose dense (DD)-MVAC (methotrexate, vinblastine [Velban, Velsar], doxorubicin [Adriamycin] and cisplatin)
enfortumab vedotin-ejfv (Padcev) and pembrolizumab (Keytruda)
MVAC - methotrexate, vinblastine (Velban, Velsar), doxorubicin (Adriamycin) and cisplatin
nivolumab (Opdivo) with cisplatin and gemcitabine (Gemzar)
As of 3/8/24