Bladder Cancer: Treatments by Stage

The information below outlines common treatments that may be part of your treatment plan, depending on the cancer’s stage (see Stages and Grades). Please note that your doctor will recommend a personalized treatment plan for you based on the stage and other factors.

In general, the main treatment options for bladder cancer are:

  • Surgery
  • Chemotherapy
  • Immunotherapy
  • Radiation therapy

To learn more about the basics of each treatment option, read this guide’s Treatment Options section.

Developing a treatment plan

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. This team is usually led by a urologist, a doctor who specializes in the genitourinary tract, which includes the kidneys, bladder, genitals, prostate, and testicles, or a urologic oncologist, a doctor who specializes in treating cancers of the urinary tract. Cancer care teams include a variety of other health care professionals, such as physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Treatment options and recommendations depend on several factors, including:

  • The type, stage, and grade of bladder cancer
  • Possible side effects
  • The patient’s preferences and overall health

Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.

The first treatment a person is given is called first-line therapy. If that treatment stops working, then a person receives second-line therapy. In some situations, third-line therapy may also be available.

Adjuvant systemic therapy is treatment that is given after surgery has been completed. In bladder cancer, adjuvant therapy is usually chemotherapy or treatment in a clinical trial. Neoadjuvant therapy is treatment that is given before surgery, such as chemotherapy.

The treatment options your doctor recommends mainly depend on the stage of bladder cancer. Treatment for cancer in the renal pelvis and/or ureter follow the same treatment plans based on the stage of the disease. However, the tumor’s size and grade may also affect which treatment options are recommended for you. Talk with your doctor about the risks and benefits of all the available treatment options and when treatment should begin. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects (see “Getting care for symptoms and side effects” in Treatment Options).

Treatments by type and stage of disease

Noninvasive and non-muscle-invasive bladder cancer (stages 0a, 0is, and I)

People with noninvasive bladder cancer (stage 0a) that is low grade are treated with TURBT first. Low-grade noninvasive bladder cancer rarely turns into aggressive or metastatic disease, but patients are at risk for developing more low-grade cancers throughout their life. This requires lifelong checkups, called surveillance, using cystoscopy (see Diagnosis). To reduce the risk of future tumors developing, people may receive intravesical chemotherapy or immunotherapy after TURBT.

Most commonly, people with high-grade noninvasive (stage 0a), carcinoma in situ (stage 0is), or non-muscle-invasive (stage I) bladder cancer are treated with TURBT, followed by intravesical immunotherapy using Bacillus Calmette-Guerin (or BCG, see “Immunotherapy” in Treatment Options). This combination of treatments is given to reduce the risk of the cancer from coming back, called recurrence, and the development of muscle-invasive disease. Before treatment with BCG, patients will need to have another TURBT to make sure that the cancer has not spread to the muscle. The first round of BCG treatment is given every week for 6 weeks. After that, the doctor performs a cystoscopy and sometimes a bladder biopsy (see Diagnosis) to see if all of the cancer has been eliminated. If the cancer is gone, patients usually have maintenance therapy with BCG, which may be given once every 3 months for the first 6 months and then once every 6 months after that, for 1 to 3 years. This will then be followed with lifelong surveillance.

People with high-grade, non-muscle-invasive bladder cancer are at higher risk for the tumor returning, called a recurrent tumor. Sometimes a tumor comes back at a more advanced stage, with a risk of developing into metastatic bladder cancer. To help prevent this from happening, the urologist may recommend removing the whole bladder, called radical cystectomy (see “Surgery” in Treatment Options), especially if the person is young and/or has a large tumor or a number of tumors at the time of diagnosis.

Muscle-invasive bladder cancer (stage II and stage III)

Muscle-invasive bladder cancer has grown into the muscle layer of the bladder wall. Surgery is often among the first treatments, and the standard treatment is a radical cystectomy (see “Surgery” in Treatment Options). Lymph nodes near the bladder are usually removed as well. A TURBT may still be done, but it usually is used to help the doctor figure out the extent of the cancer, rather than as a treatment option.

Sometimes, people with muscle-invasive bladder cancer receive systemic chemotherapy first, before surgery. Then they may have a radical cystectomy and urinary diversion or be given a combination of chemotherapy and radiation therapy. Giving chemotherapy before surgery, called neoadjuvant chemotherapy, may shrink the tumor in the bladder, destroy microscopic cancer cells that have spread beyond the bladder, and ultimately help people live longer. An important clinical trial showed that a specific combination of systemic chemotherapy called MVAC given before a radical cystectomy helped patients with muscle-invasive bladder cancer live longer. This approach is now considered a standard treatment for people whose overall health allows it. The combination of 2 other chemotherapies, cisplatin and gemcitabine, is considered a standard treatment as well, even though it has not been compared to MVAC in muscle-invasive disease.

It is important to note that neoadjuvant chemotherapy with 1 drug alone or when cisplatin is replaced with other drugs, such as carboplatin, does not seem to help patients with locally advanced bladder cancer live longer, so it is not often recommended. People whose health does not allow them to receive neoadjuvant chemotherapy should receive surgery first. Anyone who has been diagnosed with muscle-invasive bladder cancer should talk with a urologist and a medical oncologist about all of their treatment options, including the risks and benefits of chemotherapy.

An approach using chemotherapy with radiation therapy may provide the same benefits as removing the bladder. This is also known as the bladder preservation approach or trimodal therapy. The type of chemotherapy used for patients undergoing bladder radiation therapy can include cisplatin alone or a combination of a drug called mitomycin-C (Mitomycin) and fluorouracil (5-FU). It is important to talk with your doctor about the difference between these 2 different chemotherapy regimens. Be sure to discuss the differences between surgery and bladder preservation approaches, too.

Metastatic bladder cancer (stage IV)

If bladder cancer has spread to another part of the body, doctors call it metastatic bladder cancer. If this happens, it is a good idea to talk with doctors, usually medical oncologists, who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Also, clinical trials might be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

A combination of treatments may be used to help manage the cancer. There are no methods to permanently cure metastatic bladder cancer for most people. The goals of treatment are to slow the spread of cancer, shrink the tumor (called remission), and extend life for as long as possible. Palliative care is also important to help relieve symptoms and side effects.

Since there are relatively few treatment options for metastatic bladder cancer, clinical trials are often the best treatment option for most patients. Currently, the standard first-line treatment options include chemotherapy regimens that contain cisplatin- or carboplatin-based chemotherapy. These regimens include MVAC, dose-dense MVAC, and gemcitabine-cisplatin. Carboplatin-containing regimens can be used to treat patients with metastatic cancer who cannot take cisplatin. Until recently, chemotherapy with docetaxel and paclitaxel were options for second-line treatment.

Immunotherapy has changed how metastatic bladder cancer is managed. The U.S. Food and Drug Administration (FDA) recently approved 5 immune checkpoint inhibitors (see “Immunotherapy” in Treatment Options) for the treatment of people with metastatic disease who are unable to receive platinum-based chemotherapy and for those whose disease is not stopped by chemotherapy. However, the only immunotherapy that has shown to help people live longer is pembrolizumab (Keytruda). People are strongly encouraged to talk with their doctors about whether immunotherapy is right for them. Changes to these regimens or the use of new treatment regimens aimed at helping patients live longer and improve their quality of life are being studied in clinical trials.

For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.