Bladder Cancer

Page updated Winter 2021.

Disclaimer: Medicine is an ever-changing science. We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable sources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original sources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Non-Muscle Invasive Bladder Cancer

Microhematuria

Definition:

>3 red blood cells per high-power field

Evaluation:

Low-risk patients: UA within six months vs. proceeding with cystoscopy and renal ultrasound

Intermediate-Risk: cystoscopy and renal ultrasound

High-Risk: cystoscopy and axial upper

tract imaging (CT urography (including

imaging of the urothelium), or MR urography))

In case of contraindications to CT and MR: retrograde pyelography + non-contrast axial imaging or renal ultrasound

TURBT

TURBT is performed to remove all visible tumors and to provide specimens for pathology to determine stage and grade of cancer.

Repeat TURBT within 6 weeks

Should be done in following situations:

- Incomplete initial resection in a patient with non-muscle invasive disease

- T1 disease

- High-grade Ta tumors

Intravesical Instillation

Low risk disease

We recommend a single postoperative instillation of gemcitabine or mitomycin C within 24 hours of TURBT, unless there is a suspected perforation or if we performed extensive resection.

Intermediate risk disease

We recommend a single postoperative instillation of gemcitabine or mitomycin C within 24 hours of TURBT, unless there is a suspected perforation or if we performed extensive resection.

We recommend a six week course of induction intravesical chemotherapy (Mitomycin C, Doxorubicin, Epirubicin) or BCG in this group.

In patients who completely respond to induction chemotherapy or BCG, we recommend a maintenance chemotherapy or BCG instillation for one year, if tolerated.

High risk disease

We recommend a six-week induction course of BCG in this group.

In patients who completely respond to induction BCG, we recommend maintenance BCG instillation for three year, if tolerated.

Second BCG Induction

Will be offered if there is persistent or recurrent Ta or CIS disease in an intermediate- or high-risk patient.

Please note we did not include high grade T1 disease here. We offer cystectomy for high grade T1 disease.


Non-Muscle Invasive Bladder Cancer

Contraindications to Intravesical Chemotherapy


Pregnancy


Lactating


Bladder perforation


Any allergy or adverse reactions to the chemotherapeutic agent


Contraindications to Intravesical BCG


Bladder or prostate surgery or biopsy - Within 7 to 14 days


Traumatic catheterization - Within 7 to 14 days


Gross hematuria at the day of treatment


Symptomatic urinary tract infection


Febrile illness


Personal history of BCG sepsis


Personal history of tuberculosis


Immunosuppressed patients


On certain antibiotics that may interfere with effectiveness of BCG


Total incontinence (patient will not retain BCG)


Liver disease (precludes treatment with isoniazid if sepsis occurs


Advanced age


Radical Cystectomy


Initial radical cystectomy


Will be offered in following settings:


-Persistent high-grade T1 disease on repeat resection


-T1 tumors with associated with CIS


-T1 tumors with associated with Lymphovascular invasion


-T1 tumors with associated with variant histologies. These include: micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, and extensive squamous or glandular differentiation


Radical cystectomy after intravesical therapy


Will be offered in following settings:


For a high-grade T1 disease after a single course of induction intravesical BCG


For a high-risk disease with persistent or recurrent disease within one year following treatment with two induction cycles of BCG, or on BCG maintenance.


Muscle-Invasive Bladder Cancer


Radical Cystectomy Candidate


For clinically resectable stage cT2-T4a N0 M0 disease


Neoadjuvant Chemotherapy


We recommend cisplatin-based neoadjuvant chemotherapy to T2–T4a N0 M0 patients.


Cystectomy should then will be done within 12 weeks of completion of treatment.


Adjuvant Chemotherapy


We recommend adjuvant chemotherapy to pT3/T4 and/or N+ patients who have not received cisplatin-based neoadjuvant chemotherapy.


Multi-Modal Bladder Preserving Therapy


This is an option in highly selected patients.


This modality includes maximal TURBT, chemotherapy and external beam radiation therapy.


In case residual or recurrent muscle-invasive disease following bladder preserving therapy, radical cystectomy with bilateral pelvic lymphadenectomy should be done.


In case of non-muscle invasive recurrence following bladder preserving therapy, either TURBT with intravesical therapy, or radical cystectomy should be done.


Metastatic Bladder Cancer


First-line Treatment for Cisplatin-eligible Patients


GC, MVAC, HD-MVAC, PCG


First-line Treatment if Ineligible for Cisplatin


PD-L1-positive patients: Pembrolizumab or atezolizumab


PD-L1 negative patients: Carboplatin


Second-line Treatment


Pembrolizumab


Supportive Treatment in Case of Bone Metastasis


Zoledronic acid or Denosumab


Chemotherapy Regimens


GC: Gemcitabine + Cisplatin

MVAC: Methotrexate + Vinblastine + Doxorubicin + Cisplatin


HD-MVAC: High-dose-intensity chemotherapy MVAC


PCG: Paclitaxel+ Cisplatin + Gemcitabine