From the Guidelines
The prognosis for stage 4 bladder cancer is generally poor, with a 5-year survival rate of approximately 5-15%. At this advanced stage, cancer has spread beyond the bladder to distant organs like the lungs, liver, or bones. Treatment typically focuses on extending life and improving quality of life rather than cure.
Treatment Options
- Standard approaches include systemic chemotherapy regimens such as gemcitabine with cisplatin (GC) or dose-dense MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin), often given in cycles every 3-4 weeks, as supported by studies like 1.
- For eligible patients, immunotherapy with PD-L1 inhibitors like pembrolizumab (200mg IV every 3 weeks) or atezolizumab (1200mg IV every 3 weeks) may be used, especially after chemotherapy failure.
- Targeted therapies for specific genetic mutations may also be options.
- Palliative care is essential and should be integrated early to manage symptoms like pain, urinary problems, and emotional distress.
Considerations
- The prognosis varies based on individual factors including overall health, age, response to treatment, and specific sites of metastasis, with some patients surviving longer than statistical averages suggest.
- Patients unfit for cisplatin-based chemotherapy may be palliated with carboplatin-based regimen or single-agent taxane or gemcitabine, as noted in 1.
- Selected patients with locally advanced disease (T4b N1) may be candidates for cystectomy and lymph node dissection or definitive radiotherapy following systemic therapy.
- Palliative radiotherapy may be used to reduce symptoms, as mentioned in 1.
From the Research
Prognosis of Stage 4 Bladder Cancer
The prognosis for stage 4 bladder cancer is generally poor, as it often presents at a late stage when it is incurable 2.
Treatment Options
Several treatment options are available, including:
- Palliative radiotherapy, which can provide targeted long-term symptomatic control, although this must be balanced against the potential of causing toxicity 2
- Chemotherapy, such as gemcitabine and cisplatin, which can be effective in managing symptoms and improving treatment outcomes 3, 4
- Immune checkpoint inhibitors, such as pembrolizumab and nivolumab, which have shown promise in improving treatment outcomes for metastatic urothelial carcinoma 3, 4, 5, 6
Symptom Management
Palliative radiotherapy can be effective in managing local symptoms of bladder cancer, including:
- Haematuria
- Dysuria
- Frequency
- Nocturia
- Pain Radiotherapy protocols, such as 21 Gy in 3 fractions, 35 Gy in 10 fractions, and 30 Gy in 5 fractions, have been developed to manage these symptoms 2
Future Directions
Further studies are needed to better estimate the prognosis of patients presenting with bladder cancer and to define the optimal first-line therapy for metastatic urothelial carcinoma 2, 3. Ongoing research is exploring the use of combination therapies, such as gemcitabine and cisplatin plus pembrolizumab, as neoadjuvant therapy before radical cystectomy in patients with muscle-invasive bladder cancer 5, 6