Bladder Cancer: Treatments by Stage

Approved by the Cancer.Net Editorial Board, 09/2020

ON THIS PAGE: You will learn about the general types of treatments doctors use to treat people with bladder cancer based on the stage of the disease. Use the menu to see other pages.

The information below outlines common types of treatment 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 (local and systemic)

  • Targeted therapy

  • Radiation therapy

To learn more about the basics of each type of treatment, read this guide’s Types of Treatment 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, or a urologic oncologist, a doctor who specializes in treating cancers of the genitourinary tract. Cancer care teams include a variety of other health care professionals, such as physician assistants, nurse practitioners, 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 also includes treatment for symptoms and side effects, an important part of cancer care.

The first treatment a person is given for advanced urothelial cancer 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 radical surgery has been completed. In bladder cancer, adjuvant therapy is usually cisplatin-based chemotherapy (if not given before surgery) or treatment in a clinical trial. Neoadjuvant therapy is treatment that is given before surgery, such as cisplatin-based chemotherapy.

The treatments 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 can be important for relieving symptoms and side effects (see “Physical, emotional, and social effects of cancer” in Types of Treatment).

Treatment by type and stage of bladder cancer

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

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

Most commonly, people with high-grade noninvasive (stage Ta), carcinoma in situ (stage Tis), or non-muscle-invasive (stage T1) bladder cancer are treated with TURBT, followed by local intravesical Bacillus Calmette-Guerin (or BCG, see “Immunotherapy” in Types of Treatment). 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 provider 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 long-term 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 Types of Treatment), especially if the person is young and/or has a large tumor or a number of tumors at the time of diagnosis, or other aggressive features.

People with high-risk, non-muscle-invasive bladder cancer may also be treated with pembrolizumab, which is an immune checkpoint inhibitor that targets the PD-1 protein. Pembrolizumab is approved by the FDA to treat bladder cancer that has not been stopped by, or responded to, BCG treatment (also called “BCG-unresponsive”) and radical cystectomy to remove the bladder cannot be done because of other medical reasons or the patient chooses not to have that surgery.

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 Types of Treatment). 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.

Sometimes, people with muscle-invasive bladder cancer receive systemic chemotherapy first, before surgery. Then they may have a radical cystectomy and urinary diversion or may be given a combination of chemotherapy and radiation therapy. Giving 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 radical cystectomy helped people with muscle-invasive bladder cancer live longer. This approach is now a standard treatment for people whose overall health allows it. The combination of 2 chemotherapy drugs, cisplatin and gemcitabine, is also considered a standard regimen for neoadjuvant therapy in muscle-invasive disease.

It is important to note that neoadjuvant chemotherapy should be a cisplatin-based combination. People whose health does not allow them to receive neoadjuvant cisplatin-based chemotherapy may receive radical surgery first (or enroll in clinical trial). Anyone who has been diagnosed with muscle-invasive bladder cancer should talk with a urologist, a medical oncologist, and a radiation oncologist about all their treatment options, including the risks and benefits of radical surgery, chemotherapy, or radiation therapy, ideally in a multidisciplinary setting.

Bladder preservation

An approach using chemotherapy with radiation therapy after optimal TURBT 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, gemcitabine alone, or a combination of a drug called mitomycin-C (available as a generic drug) and fluorouracil (5-FU). It is important to talk with your doctor about the difference between these 3 different chemotherapy regimens. Be sure to discuss the differences between surgery and bladder preservation approaches in detail, as well as all applicable clinical trials.

Metastatic urothelial 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. Clinical trials may also be a good 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 urothelial cancer for most people. The goals of treatment are to slow the spread of cancer, delay its growth, shrink the tumor (called remission), and extend life for as long as possible. Palliative care is also important to help relieve cancer symptoms and treatment side effects.

Since there are relatively few treatment options for metastatic urothelial cancer, clinical trials are often the best treatment option for most patients. 

Chemotherapy. Currently, the standard first-line treatment options include chemotherapy regimens that contain cisplatin or carboplatin. These regimens include MVAC (rarely), dose-dense MVAC, and gemcitabine-cisplatin. Carboplatin regimens, such as with gemcitabine, can be used to treat people with metastatic urothelial cancer who cannot receive cisplatin. Chemotherapy with docetaxel or paclitaxel or pemetrexed are options for later-line treatment.

Immunotherapy (updated 03/2021). Systemic immunotherapy has changed how metastatic urothelial cancer is managed. The FDA has approved several immune checkpoint inhibitors (see “Immunotherapy” in Types of Treatment) for the treatment of people with metastatic disease whose disease is not shrunk or stabilized by platinum-based chemotherapy. However, the only immunotherapy that has shown to help people live longer in this setting in a phase 3 clinical trial is pembrolizumab. Switch maintenance therapy with avelumab is also shown to make people live longer and reduce the risk of the cancer worsening if there is no cancer growth with platinum-based chemotherapy. 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 aiming at helping patients live longer, have lower risk of recurrence, and improve their quality of life are being studied in many clinical trials.

Targeted therapy. In 2019, the FDA approved erdafitinib to treat people with locally advanced or metastatic urothelial carcinoma after platinum chemotherapy did not stop the cancer. Erdafitinib is a targeted therapy aimed at the DNA changes in the FGFR2 or FGFR3 genes. Patients must have their tumor tested for these changes to be able to receive the treatment. The FDA also approved enfortumab vedotin-ejfv (Padcev), an antibody-drug conjugate, to treat locally advanced (unresectable) or metastatic urothelial carcinoma in people who have also received a PD-1 or PD-L1 immune checkpoint inhibitor and platinum chemotherapy. Learn more in the “Therapies using medication” section in Types of Treatment.

For most people, a diagnosis of metastatic cancer is very stressful and difficult. You and your family are encouraged to talk about how you feel 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.

The next section in this guide is About Clinical TrialsIt offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.