The most important part of managing patients with low-grade non-invasive bladder cancer is putting them on a strict regimen of surveillance to monitor the bladder to detect recurrences early so that can be easily taken care of. Some patients who have low-grade non invasive disease, even though it’s not a life-threatening situation, will have multiple recurrences that are quite a nuisance problem and some of these patients may require more aggressive treatment with a form of chemotherapy that is placed into the bladder to try to prevent recurrences from developing. 

Patients who are found to have high-grade bladder cancer, that is either in the form of carcinoma in situ non-invasive tumors, or tumors that have just invaded the very surface of the bladder need more aggressive treatment. The reason for this is because without further treatment beyond the initial scraping of the tumor, these patients over time have a high risk of the cancer not only recurring, but progressing to a more invasive problem that has a chance to spread and cause significant problems and even death. So for these patients that have high grade disease after the initial scraping the recommended treatment is immunotherapy or chemotherapy that is placed within the bladder following the resection of the tumor. 

The most common and effective treatment in this setting is the use of BCG. This is a type of immunotherapy that works through the patient’s own immune system. It is administered intravesically, meaning that it is placed into the bladder. The way it works is that a patient will come to the office, the bladder will be drained by a catheter and the BCG is instilled into the bladder. What this does then is we’re intentionally causing a special type of bladder infection. BCG is actually a vaccine that’s used in other parts of the world to prevent TB, but when administered into the bladder, it stimulates a TB type of infection within the bladder. This infection then stimulates the patient’s body’s own immune fighting cells, disease fighting, cells to come to the bladder. In the process they eliminate the BCG over time, but they also recognize cancer cells and can eliminate them from the bladder as well, and this has proved to be a quite effective treatment for bladder cancer, especially for patients that have high grade disease that has a chance for progressing to more invasive and even metastatic disease. 

Occasionally, some patients are not suitable for BCG because of other illnesses that typically involve their immune system. And these patients, even though it may be less effective, chemotherapy placed into the bladder may be used with the same rationale to try to prevent these cancers from recurring down the road. Patients who are found to have high-grade bladder cancer that is more invasive that is invading into the muscle wall itself of the bladder or even beyond, have a very potentially life-threatening situation. These patients require aggressive therapy. Following further staging studies which are performed to make sure that the cancer has not spread widely throughout the body, these patients are typically treated with aggressive surgery to remove the bladder and the surrounding lymph nodes. In the majority of these patients, surgery, oftentimes by itself, is inadequate and chemotherapy is recommended to consider, for most of these patients, either administered before the surgery or after, to increase the chance of cure. 

This brings up an important point in the management of patients who have invasive bladder cancers. That is, these patients are best treated with a multidisciplinary approach. The best outcomes are typically obtained when a team of physicians, involving surgeons, medical oncologists who administer chemotherapy and even radiation therapists, can work together to determine the best treatment plan for this potentially deadly situation. Although removal of the bladder and chemotherapy oftentimes is the most common treatment for patients with invasive bladder cancer, at times because of patient preference or also because of patients who have significant medical problems that make surgery too risky. Another alternative for management is a combination of chemotherapy and radiation therapy. This is actually a common treatment used in some parts of Europe, but less commonly used in the United States. However, in properly selected patients, outcomes similar to that reported with surgical removal of the bladder can be obtained.