This resource was originally published by the National Cancer Institute, here.

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Treatment Option Overview

• There are different types of treatment for patients with bladder cancer.
• Five types of standard treatment are used:
  • Surgery
  • Radiation therapy
  • Chemotherapy
  • Immunotherapy
  • Targeted therapy
• New types of treatment are being tested in clinical trials.
• Treatment for bladder cancer may cause side effects.
• Patients may want to think about taking part in a clinical trial.
• Patients can enter clinical trials before, during, or after starting their cancer treatment.
• Follow-up tests may be needed.

There are different types of treatment for patients with bladder cancer.

Different types of treatment are available for patients with bladder cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

Surgery

One of the following types of surgery may be done:

• Transurethral resection (TUR) with fulguration: Surgery in which a cystoscope (a thin lighted tube) is inserted into the bladder through the urethra. A tool with a small wire loop on the end is then used to remove the cancer or to burn the tumor away with high-energy electricity. This is known as fulguration.
• Radical cystectomy: Surgery to remove the bladder and any lymph nodes and nearby organs that contain cancer. This surgery may be done when the bladder cancer invades the muscle wall, or when superficial cancer involves a large part of the bladder. In men, the nearby organs that are removed are the prostate and the seminal vesicles. In women, the uterus, the ovaries, and part of the vagina are removed. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to reduce urinary symptoms caused by the cancer. When the bladder must be removed, the surgeon creates another way for urine to leave the body.
• Partial cystectomy: Surgery to remove part of the bladder. This surgery may be done for patients who have a low-grade tumor that has invaded the wall of the bladder but is limited to one area of the bladder. Because only a part of the bladder is removed, patients are able to urinate normally after recovering from this surgery. This is also called segmental cystectomy.
• Urinary diversion: Surgery to make a new way for the body to store and pass urine.

After the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy after surgery to kill any cancer cells that are left. Treatment given after surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). For bladder cancer, regional chemotherapy may be intravesical (put into the bladder through a tube inserted into the urethra). The way the chemotherapy is given depends on the type and stage of the cancer being treated. Combination chemotherapy is treatment using more than one anticancer drug.

Immunotherapy

Immunotherapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This cancer treatment is a type of biologic therapy.

There are different types of immunotherapy:

• PD-1 and PD-L1 inhibitor therapy: PD-1 is a protein on the surface of T cells that helps keep the body’s immune responses in check. PD-L1 is a protein found on some types of cancer cells. When PD-1 attaches to PD-L1, it stops the T cell from killing the cancer cell. PD-1 and PD-L1 inhibitors keep PD-1 and PD-L1 proteins from attaching to each other. This allows the T cells to kill cancer cells.
  • Pembrolizumab and nivolumab are types of PD-1 inhibitors.
  • Atezolizumab, avelumab, and durvalumab are types of PD-L1 inhibitors.
• BCG (bacillus Calmette-Guérin): Bladder cancer may be treated with an intravesical immunotherapy called BCG. The BCG is given in a solution that is placed directly into the bladder using a catheter (thin tube).

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack certain cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do.

The following targeted therapies are approved for patients with bladder cancer that is locally advanced or has spread to other parts of the body:

• Enfortumab vedotin is a monoclonal antibody linked to an anticancer drug. This is called an antibody-drug conjugate. It may be used in patients whose cancer has become worse after treatment with an immune checkpoint inhibitor and chemotherapy (cisplatin or carboplatin-based therapy).
• Erdafitinib is a tyrosine kinase inhibitor. It may be used in patients with bladder cancer that has certain mutations in the FGFR genes and which has become worse after treatment with chemotherapy (cisplatin or carboplatin-based therapy).
• Ramucirumab is a type of targeted therapy that is being studied in combination with chemotherapy for the treatment of bladder cancer. It blocks VEGF to help keep new blood vessels from forming. This may keep cancer cells from growing and may kill them. It is a type of angiogenesis inhibitor and a type of monoclonal antibody.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.