From the Guidelines
Bladder cancer treatment should be guided by the most recent NCCN guidelines, which recommend transurethral resection of the bladder tumor (TURBT) followed by intravesical therapy with BCG (Bacillus Calmette-Guérin) or chemotherapy agents like mitomycin C for non-muscle invasive bladder cancer, and radical cystectomy (bladder removal) with urinary diversion, often combined with neoadjuvant chemotherapy, for muscle-invasive disease 1. The clinical spectrum of bladder cancer can be divided into three categories that differ in prognosis, management, and therapeutic aims.
- Non–muscle-invasive bladder cancer, which accounts for approximately 75% of newly detected cases, is typically treated with TURBT and intravesical therapy to reduce recurrences and prevent progression to a more advanced stage.
- Muscle-invasive bladder cancer requires more aggressive therapy, often a multidisciplinary approach including a combination of systemic therapy, surgery, and/or radiation.
- Metastatic bladder cancer treatment focuses on prolonging survival and maintaining quality of life, with numerous agents having antitumor effects on this disease. Risk factors for developing bladder cancer include male sex, white race, smoking, personal or family history of bladder cancer, pelvic radiation, environmental/occupational exposures, exposure to certain medications, chronic infection or irritation of the urinary tract, and certain medical conditions, such as obesity and diabetes 1. Regular follow-up with cystoscopy and imaging is crucial after treatment, as bladder cancer has a high recurrence rate. Smoking cessation, staying hydrated, and limiting exposure to industrial chemicals can help reduce the risk of developing bladder cancer 1.
From the Research
Bladder Cancer Overview
- Bladder cancer is the sixth most prevalent malignancy in the United States, causing more than 16,000 deaths annually 2
- The most common clinical presentation is asymptomatic hematuria, which should prompt evaluation with cystoscopy, renal function testing, and upper urinary tract imaging in adults 35 years and older 2
Diagnosis and Treatment
- Transurethral resection of the bladder tumor allows for definitive diagnosis, staging, and primary treatment 2
- Non-muscle-invasive disease is treated with transurethral resection, most often followed by intravesical bacille Calmette-Guérin or intravesical chemotherapy 2
- Bladder cancer that invades the muscle layer is typically treated with radical cystectomy and neoadjuvant chemotherapy because of higher rates of progression and recurrence 2
Bacillus Calmette-Guérin (BCG) Immunotherapy
- BCG immunotherapy is the standard of care for high-grade non-muscle invasive bladder cancer (NMIBC) and carcinoma in-situ (CIS) in terms of prevention of recurrence and progression 3
- BCG immunotherapy is currently the most effective treatment of non-muscle invasive bladder cancer and one of the most successful applications of immunotherapy to the treatment of cancer 3
- The 3-week maintenance schedule for 3 years has been evaluated in randomised clinical trials and appears to be the current optimal treatment 3
Safety and Efficacy of BCG Immunotherapy
- BCG intravesical therapy can be offered to immunomodulated patients with high-risk NMIBC, although theoretical infectious complication risks remain 4
- Rates of bladder cancer progression and disseminated BCG complications 5-years after BCG therapy were similar regardless of immunomodulation status 4
- BCG-induced immunity in NMIBC is not yet fully understood, but animal studies point towards BCG inducing specific tumour immunity 5
Side Effects and Complications of BCG Immunotherapy
- Side effects of BCG bladder instillations range from common, mild and transient symptoms, such as dysuria and flu-like symptoms, to more severe and rarely occurring life-threatening complications 5
- Recent studies also indicate that dysbiosis of the urinary microbiome may cause lower urinary tract dysfunction 5