Bladder Cancer: Types of Treatment

Approved by the Cancer.Net Editorial Board, 05/2019

ON THIS PAGE: You will learn the basics about the different types of treatments doctors use for people with bladder cancer. Use the menu to see other pages.

This section explains the types of treatments that are the standard of care for bladder cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

Treatment overview

Basic descriptions of the most common types of treatments used for bladder cancer are listed below. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for bladder cancer because there are different treatment options. Learn more about making treatment decisions.

To see general treatment options based on the extent of the bladder cancer, read the next section in this guide, Treatments by Stage.

Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. There are different types of surgery for bladder cancer. Your health care team will recommend a specific surgery based on the stage and grade of the disease. Surgical options to treat bladder cancer include:

  • Transurethral bladder tumor resection (TURBT). This procedure is used for diagnosis and staging, as well as treatment. During TURBT, a surgeon inserts a cystoscope through the urethra into the bladder. The surgeon then removes the tumor using a tool with a small wire loop, a laser, or fulguration (high-energy electricity). The patient is given an anesthetic, medication to block the awareness of pain, before the procedure begins.

    For people with non-muscle-invasive bladder cancer, TURBT may be able to eliminate the cancer. However, the doctor may recommend additional treatments to lower the risk of the cancer returning, such as intravesical chemotherapy or immunotherapy (see below). For people with muscle-invasive bladder cancer, additional treatments involving surgery to remove the bladder or, less commonly, radiation therapy are usually recommended.

  • Radical cystectomy and lymph node dissection. A radical cystectomy is the removal of the whole bladder and possibly nearby tissues and organs. For men, the prostate and urethra also may be removed. For women, the uterus, fallopian tubes, ovaries, and part of the vagina may be removed. For all patients, lymph nodes in the pelvis are removed. This is called a pelvic lymph node dissection. An extended pelvic lymph node dissection is the most accurate way to find cancer that has spread to the lymph nodes. Rarely, for some specific cancers, it may appropriate to remove only part of the bladder, which is called partial cystectomy. However, this surgery is not the standard of care for people with muscle-invasive disease.

    During a laparoscopic or robotic cystectomy, the surgeon makes several small incisions, or cuts, instead of the 1 larger incision used for traditional surgery. The surgeon then uses telescoping equipment with or without robotic assistance to remove the bladder. The surgeon must make an incision to remove the bladder and surrounding tissue. This type of operation requires a surgeon who is very experienced in minimally invasive surgery. Several studies are still in progress to determine whether laparoscopic or robotic cystectomy is as safe as the standard surgery and whether it is able to eliminate bladder cancer as successfully as standard surgery.

  • Urinary diversion. If the bladder is removed, the doctor will create a new way to pass urine out of the body. One way to do this is to use a section of the small intestine or colon to divert urine to a stoma or ostomy (an opening) on the outside of the body. The patient then must wear a bag attached to the stoma to collect and drain urine.

    Surgeons can sometimes use part of the small or large intestine to make a urinary reservoir, which is a storage pouch that sits inside the body. With these procedures, the patient does not need a urinary bag. For some patients, the surgeon is able to connect the pouch to the urethra, creating what is called a neobladder or "Indiana pouch", so the patient can pass urine out of the body normally. However, the patient may need to insert a thin tube called a catheter if the neobladder is not fully emptied of urine. Also, patients with a neobladder will no longer have the urge to urinate and will need to learn to urinate on a consistent schedule.For other patients, an internal (inside the abdomen) pouch made of small intestine is created and connected to the skin on the abdomen or belly button (umbilicus) through a small stoma. With this approach, patients do not need to wear a bag. Patients drain the internal pouch multiple times a day by inserting a catheter through the small stoma and immediately removing the catheter.

Living without a bladder can affect a patient’s quality of life. Finding ways to keep all or part of the bladder is an important treatment goal. For some people with muscle-invasive bladder cancer, treatment plans involving chemotherapy and radiation therapy (see below) may be used as an alternative to removing the bladder.

The side effects of bladder cancer surgery depend on the procedure. Research has shown that having a surgeon with bladder cancer expertise can improve the outcome of people with bladder cancer. Patients should talk with their doctor in detail to understand exactly what side effects may occur, including urinary and sexual side effects, and how they can be managed. In general, side effects may include:

  • Longer healing time

  • Infection

  • Mild bleeding and discomfort after surgery

  • Infections or urine leaks after cystectomy or a urinary diversion. If a neobladder has been created, a patient may sometimes be unable to urinate or completely empty the bladder.

  • Men may be unable to have an erection, called erectile dysfunction, after cystectomy. Sometimes, a nerve-sparing cystectomy can be performed. When this is done successfully, men may be able to have a normal erection.

  • Damage to the nerves in the pelvis and loss of sexual feeling and orgasm for both men and women. Often, these problems can be fixed with further treatment.

Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for bladder cancer include:

  • Chemotherapy

  • Immunotherapy

  • Targeted therapy

Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells. A chemotherapy regimen, or schedule, typically consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time.

There are 2 types of chemotherapy that may be used to treat bladder cancer. The type the doctor recommends and when it is given depends on the stage of the cancer. Patients should talk with their doctor about chemotherapy before surgery.

  • Intravesical chemotherapy. Intravesical, or local, chemotherapy is usually given by a urologist. During this type of therapy, drugs are delivered into the bladder through a catheter that has been inserted through the urethra. Local treatment only destroys superficial tumor cells that come in contact with the chemotherapy solution. It cannot reach tumor cells in the bladder wall or tumor cells that have spread to other organs. Mitomycin-C (available as a generic drug), gemcitabine (Gemzar), and thiotepa (Tepadina) are the drugs used most often for intravesical chemotherapy. Other drugs that are used include cisplatin (available as a generic drug), doxorubicin (available as a generic drug), and valrubicin (Valstar).

  • Systemic chemotherapy. The most common regimens for systemic, or whole-body, chemotherapy to treat bladder cancer include:

    • Cisplatin and gemcitabine

    • Carboplatin (available as a generic drug) and gemcitabine

    • MVAC, which combines 4 drugs: methotrexate (Rheumatrex, Trexall), vinblastine (Velban), doxorubicin, and cisplatin

    • Dose-dense (DD)-MVAC with growth factor support: This is the same regimen as MVAC, but there is less time between treatments

Many systemic chemotherapies continue to be tested in clinical trials to help find out which drugs or combinations of drugs work best to treat bladder cancer. Usually a combination of drugs works better than 1 drug alone. Researchers are also studying when it is best to use chemotherapy, either before or after surgery.

Side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away after treatment is finished.

Learn more about the basics of chemotherapy.

Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. It can be given locally or throughout the body.

Local therapy
  • Bacillus Calmette-Guerin (BCG). The standard immunotherapy drug for bladder cancer is a weakened bacterium called BCG, which is similar to the bacteria that causes tuberculosis. BCG is placed directly into the bladder through a catheter. This is called intravesical therapy. BCG attaches to the inside lining of the bladder and stimulates the immune system to destroy the tumor. BCG can cause flu-like symptoms, chills, mild fever, fatigue, a burning sensation in the bladder, and bleeding from the bladder.

  • Interferon (Roferon-A, Intron A, Alferon). Interferon is another type of immunotherapy that can be given as intravesical therapy. It is sometimes combined with BCG if using BCG alone does not help treat the cancer.

Systemic therapy
  • Immune checkpoint inhibitors. An active area of immunotherapy research is looking at drugs that block a protein called PD-1. PD-1 is found on the surface of T cells, which are a type of white blood cell that directly helps the body’s immune system fight disease. Because PD-1 keeps the immune system from destroying cancer cells, stopping PD-1 from working allows the immune system to better eliminate the cancer. Atezolizumab (Tecentriq), nivolumab (Opdivo), avelumab (Bavencio), durvalumab (Imfinzi), and pembrolizumab (Keytruda) are all used to treat advanced or metastatic urothelial carcinoma. Atezolizumab, durvalumab, and avelumab are PD-L1 inhibitors, which also interact with the PD-1 protein on T cells. Pembrolizumab, like nivolumab, is a PD-1 inhibitor. Pembrolizumab is the only immunotherapy that has been shown to help people live longer after a first treatment with chemotherapy did not work. Pembrolizumab and atezolizumab can also help certain people who cannot receive cisplatin-based chemotherapy and have tumors that overexpress PD-L1. People who cannot receive any platinum chemotherapy can receive immunotherapy regardless of whether their tumors overexpress PD-L1. Several other immune checkpoint inhibitors are currently being studied in a clinical trials.

Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.

Targeted therapy for bladder cancer includes erdafitinib (Balversa). Erdafitinib is a drug given by mouth (orally) that is approved to treat people with locally advanced or metastatic urothelial carcinoma with FGFR3 or FGFR2 genetic mutations after receiving platinum chemotherapy. There is a specific FDA-approved companion test to find out who may benefit most from treatment with erdafitinib.

Common side effects of erdafitinib include increased phosphate level, mouth sores, feeling tired or fatigue, change in kidney function, diarrhea, dry mouth, nails separating from the nail bed or poor formation of the nail, change in liver function, low salt (sodium) levels, decreased appetite, change in sense of taste, low red blood cells (anemia), dry skin, dry eyes, and hair loss. Erdafitinib may also cause rare but serious eye problems, including central serous retinopathy/retinal pigment epithelial detachment (CSR/RPED), which could cause blind spots that are called visual field defects.

Talk with your doctor about possible side effects for a specific medication and how they can be managed.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy. However, brachytherapy is not commonly used in bladder cancer. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.

Radiation therapy is usually not used by itself as a primary treatment for bladder cancer, but it may be given in combination with chemotherapy. Some people who cannot receive chemotherapy might receive radiation therapy alone. Combined radiation therapy and chemotherapy may be used to treat cancer that is located only in the bladder:

  • To destroy any cancer cells that may remain after TURBT, so all or part of the bladder does not have to be removed.

  • To relieve symptoms caused by a tumor, such as pain, bleeding, or blockage.

  • To treat a metastasis located in 1 area, such as the brain or bone.

Side effects from radiation therapy may include fatigue, mild skin reactions, and loose bowel movements. For bladder cancer, side effects most commonly occur in the pelvic or abdominal area and may include bladder irritation, with the need to pass urine frequently during the treatment period, and bleeding from the bladder or rectum. Most side effects go away soon after treatment is finished.

Learn more about the basics of radiation therapy.

Physical, emotional, and social effects of cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel feels during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence, also known as metastasis).

When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options.

In general, non-muscle-invasive bladder cancers that come back in the same location as the original tumor or somewhere else in the bladder are treated in the same way as the first cancer. However, if the cancer continues to return after treatment, a cystectomy may be recommended. Bladder cancers that recur outside the bladder are more difficult to eliminate with surgery and are often treated with therapies using medication, radiation therapy, or both. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.

If treatment does not work

Recovery from bladder cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

Patients who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is a specific type of palliative care designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

Information about the cancer’s stage and grade will help the doctor recommend a specific treatment plan. The next section in this guide is Treatments by Stage. Use the menu to choose a different section to read in this guide.