Patients with Stage I bladder cancer have a cancer that invades the subepithelial connective tissue, but does not invade the muscle of the bladder and has not spread to lymph nodes. Stage I disease is classified as a “superficial” bladder cancer. A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.
The following is a general overview of the treatment of Stage I bladder cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied to your situation. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.
Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.
Standard initial treatment for all patients with Stage I bladder cancer is a transurethral resection (TUR) with electrical (cautery) or laser thermal destruction of all visualized cancer. A TUR is an operation that is performed for both the diagnosis and management of bladder cancer. During a TUR, a urologist inserts a thin, lighted tube called a cystoscope into the bladder through the urethra to examine the lining of the bladder. The urologist can remove samples of tissue through this tube or can remove some or all of the cancer in the bladder.
Rarely, for more extensive or multiple superficial cancers, a segmental cystectomy (removal of part of the bladder) is necessary. Even more rarely, radical cystectomy (complete removal of the bladder) is used for extensive multiple superficial cancers. To learn more about TUR, go to Surgery for Bladder Cancer.
Surgery (TUR) alone is effective in preventing recurrences in approximately 50% of patients with superficial bladder cancer. Failure of treatment is usually due to the appearance of new superficial cancers, which can be retreated with TUR and cautery or laser therapies. Within 15 or 20 years, more than half of surviving patients will have experienced progressive cancer or, more commonly, will develop new cancers, including cancers of the upper urinary tract (ureters and renal pelvis). Approximately 20-30% of these cancers will require treatment with a cystectomy.
Because this is a cancer of older individuals, many patients will die of other causes before progression of bladder cancer. However, approximately 25% of patients treated for superficial bladder cancer will ultimately die of bladder cancer. Because the risk of developing invasive bladder cancer never goes away, it is important to have frequent follow-up examinations (cystoscopy) no matter what form of therapy is selected. It is extremely important to detect early progression because there are effective treatments for small advanced bladder cancers.
Bladder cancer frequently recurs, and it is important to develop strategies to prevent these recurrences. Adjuvant therapy is additional treatment that increases the effectiveness of a primary therapy. The goal of adjuvant therapy is to improve the chance of cure, prevent cancer from recurring or progressing to a worse stage, and/or improve the duration of overall survival. Adjuvant therapy for Stage I bladder cancer typically consists of immunotherapy and/or chemotherapy delivered directly into the bladder through the urethra (intravesical therapy).
Patients with Stage I bladder cancer are at risk not only for superficial cancer recurrences, but also for progression to more aggressive invasive bladder cancers. All patients with this stage of disease should consider adjuvant treatment.
Bladder instillation of Bacille Calmette-Guérin (BCG): Bacille Calmette-Guérin (BCG) is one of the most common adjuvant therapies for treatment of superficial bladder cancer.1 BCG is an immunotherapy derived from a weakened form of the bacterium related to bacteria causing tuberculosis. BCG is instilled directly into the bladder through the urethra and exerts its anticancer effect by stimulating the body’s immune system to kill cancer cells. The primary side effects of BCG are pain in the bladder, blood in the urine and rarely, autoimmune disorders. Because BCG is a live bacteria, it may occasionally grow and cause an infection that requires antibiotic treatment.
Compared with treatment of superficial bladder cancer with TUR alone, treatment with TUR and intravesical BCG reduces the risk of recurrence and may also reduce the risk of cancer progression.2 However, even with optimal BCG therapy, almost half of all patients with superficial bladder cancer will ultimately have progression to invasive bladder cancer. This indicates the importance of frequent follow-up examinations (cystoscopy) to detect early progression to invasive cancer or new superficial cancers. Early invasive bladder cancer can be treated effectively.
Bladder Instillation of Chemotherapy: Instillation of chemotherapy drugs (mitomycin, thiotepa, or doxorubicin) into the bladder can reduce the incidence of superficial cancer recurrences, but no single drug has been confirmed to reduce progression of superficial cancer to invasive bladder cancer. This means that multiple small new cancers can be prevented but progression to a more invasive bladder cancer may occur despite treatment.
The optimal time to administer chemotherapy is immediately after TUR as the drugs might prevent reseeding of cancer cells disrupted with surgery. Mitomycin is probably the preferred drug because it produces few side effects and is not well absorbed into the system, which allows more of the drug to remain in the bladder to treat the cancer. Thiotepa is rapidly absorbed and produces low blood counts. Doxorubicin produces the most local side effects.
Strategies to Improve Treatment
The progress that has been made in the treatment of bladder cancer has resulted from improved surgical techniques, development of adjuvant treatments and doctor and patient participation in clinical studies. Future progress in the treatment of bladder cancer will result from continued participation in appropriate studies. Currently, there are several areas of active exploration aimed at improving the treatment of bladder cancer.
Keytruda Immunotherapy: The Food and Drug Administration (FDA) approved Keytruda (pembrolizumab) for the treatment of patients with Bacillus Calmette-Guerin (BCG)-unresponsive, high-risk, non-muscle invasive bladder cancer with carcinoma in situ (CIS) with or without papillary tumors who are ineligible for or have elected not to undergo cystectomy. Keytruda produced a complete response rate of 41% and an average response duration of 16.2 months.3
Photodynamic Therapy: Photodynamic therapy combines a photosensitizer, such as Photofrin®, with red laser light to destroy cancer cells. The photosensitizer is injected into a vein, travels through the bloodstream and is picked up and incorporated into cancer cells. When the laser is directed at the cancer, the photosensitizer in the cancer cell captures the light from the laser, which kills the cell.
Photodynamic therapy was evaluated in 58 patients with resistant superficial bladder cancer (papillary and carcinoma in situ) who could not receive local treatment with chemotherapy or BCG immunotherapy.4 With a single photodynamic treatment, 84% of patients with residual resistant papillary transitional cell carcinoma and 75% of patients with refractory carcinoma in situ experienced a complete response or disappearance of all cancer. At four years from treatment, 59% of the patients responding to treatment were alive and 31 of 34 survived without cancer recurrence. Photodynamic therapy appears to be a safe and effective treatment for refractory carcinoma in situ or recurrent papillary transitional cell carcinoma. Clinical trials are ongoing to determine how best to utilize this form of treatment.
Combining Other Agents with BCG: BCG is the most active treatment modality for superficial bladder cancer. In general, adding chemotherapy to BCG has not been successful. The results of a clinical trial conducted among patients with Stage I bladder cancer, however, suggest that the combination of BCG and electromotive mitomycin C (mitomycin delivered with the assistance of electric current) may be more effective than BCG alone.5 The addition of other biologic agents to BCG, such as interferon alpha, interleukin-2 and interleukin 12, is also being evaluated.
1 National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology.™ Bladder Cancer. V.2.2008. © National Comprehensive Cancer Network, Inc. 2008. NCCN and NATIONAL COMPREHENSIVE CANCER NETWORK are registered trademarks of National Comprehensive Cancer Network, Inc.
2 Dalbagni G. The management of superficial bladder cancer. Nature Clinical Practice Urology. 2007. 4:254-260.
3FDA approves pembrolizumab for BCG-unresponsive, high-risk non-muscle invasive bladder cancer
4 Nseyo UO, DeHaven J, Dougherty TJ et al. Photodynamic therapy (PDT) in the treatment of patients with resistant superficial bladder cancer: a long-term experience. Journal of Clinical Laser Medicine and Surgery. 1998;16:61-8.
5 Stasi S, Giannantoni A, Giurioli A, et al. Sequential BCG and electromotive mitomycin versus BCG alone for high-risk superficial bladder cancer: a randomized controlled trial. Lancet Oncology. 2006; 7: 43-51.