Bladder Cancer Treatment Guidelines

Introduction to Bladder Cancer Treatment

The National Comprehensive Cancer Network recommends that the treatment of bladder cancer should be based on tumor stage, grade, and depth of invasion, with options ranging from transurethral resection with intravesical therapy for non-muscle invasive disease to radical cystectomy with neoadjuvant chemotherapy for muscle-invasive tumors 1, 2

Complete transurethral resection of bladder tumor (TURBT) is the primary treatment for any initial bladder tumor, according to the European Association of Urology 3
Multiple selective and/or random biopsies should be performed for suspected or known carcinoma in situ, as recommended by the National Comprehensive Cancer Network 1
Repeat TURBT is necessary if no muscle is present in the specimen for high-grade disease, any T1 lesion is present, or the first resection does not allow adequate staging, as per the National Comprehensive Cancer Network guidelines 1
For low-risk tumors, the American Urological Association recommends observation or single-dose intravesical chemotherapy within 24 hours, with cystoscopy follow-up at 3 months, and increasing intervals as appropriate 2
For intermediate-risk tumors, the European Association of Urology suggests multiple chemotherapeutic instillations, and intravesical chemotherapy with mitomycin, with a strength of evidence of category 1 2, 3
For high-risk tumors, the National Comprehensive Cancer Network recommends BCG intravesical therapy, which has been shown to prevent recurrences and reduce mortality by 23%, with a high level of evidence 2, 4, 5

Radical cystectomy with extended lymphadenectomy is the standard treatment for MIBC, according to the European Association of Urology, and should include bilateral pelvic lymphadenectomy 7, 8
The National Comprehensive Cancer Network strongly recommends considering neoadjuvant cisplatin-based combination chemotherapy before cystectomy, with a category 1 strength of evidence 2, 6
Segmental (partial) cystectomy may be considered for solitary lesions in locations amenable to segmental resection with adequate margins, and no carcinoma in situ present, as per the National Comprehensive Cancer Network guidelines 1
Bladder preservation approaches, such as trimodality therapy, may be considered for initial T2 tumors <5 cm, with no CIS, and good performance status, according to the European Association of Urology 2, 7

Platinum-based combination chemotherapy (MVAC or gemcitabine-cisplatin) is recommended as first-line therapy for advanced/metastatic bladder cancer, with a category 1 strength of evidence, according to the European Association of Urology 6, 3

After radical cystectomy, the National Comprehensive Cancer Network recommends urine cytology, creatinine, and electrolytes every 3-6 months for 2 years, then as clinically indicated, with imaging of chest, abdomen, and pelvis every 3-12 months for 2 years based on recurrence risk 1
After bladder preservation, the European Association of Urology suggests cystoscopy and urinary cytology every 3 months during the first 2 years, then every 6 months, with consideration of imaging of the upper tract every 1-2 years for high-grade tumors 7, 2