How is bladder cancer treated?

Removing stage Ta and stage T1 tumors: Transurethral resection of the bladder (TURBT) is the usual treatment method for patients who, when examined with a cystoscope, are found to have abnormal growths on the urothelium (stage Ta) and/or in the lamina propria (stage T1). 
Alternative methods, such as laser therapy, compare favorably with TURBT in terms of treatment results. However, TURBT has the major advantage of providing tissue suitable for a pathologist to use in determining a tumor's grade and stage. The tumor structure is left too distorted for this purpose after the alternative treatment methods, so biopsies of the tumor must be taken before treatment.
Intravesical chemotherapy and immunotherapy:  Following removal, intravesical chemotherapy or intravesical immunotherapy may be used to try to prevent tumor recurrences. Intravesical means "within the bladder". These therapeutic agents are put directly into the bladder through a catheter in the urethra (the catheter only stays in for a few minutes), are retained for one to two hours and are then urinated out.
The chief intravesical agents currently available are thiotepa, doxorubicin, mitomycin C and bacillus Calmette-Guerin (BCG). The first three are chemotherapy drugs. The fourth, BCG, is a live but weakened vaccine strain of bovine tuberculosis. It was first used to immunize humans against tuberculosis. It is now one of the most effective agents for treating bladder cancer and especially for treating CIS.
All four agents have some benefits and risks. Among the benefits:  Comparison studies have shown each of the four to be superior to TURBT alone for preventing tumor recurrences following TURBT. Studies have also shown both BCG and mitomycin C to be superior to doxorubicin or thiotepa for reducing recurrence of T1 tumors and high-grade Ta tumors. However, there is no absolute evidence that any intravesical therapy affects the rate of progression to muscle-invasive disease although some studies with BCG suggest this may be the case.
Among the risks:  Each of the four agents produces irritative side effects such as painful urination and the need to urinate frequently. In addition, BCG therapy carries a 24 percent risk of flu-like symptoms and a small risk (4 percent) of systemic infections. Thiotepa has a 13 percent risk of suppressing bone marrow activity — causing a reduction in white blood cells and platelets. The main side effects for each intravesical agent are shown in Table 2, along with estimated probabilities of occurrence.

Table 2: Side effects of treatment and estimated probabilities of occurrence Intravesical Agent
Side Effects	BCG	Mitomycin C	Thiotepa	Doxorubicin
Frequent urination	63%	42%	11%	27%
Painful urination	75%	35%	30%	20%
Flu-like symptoms	24%	20%	11%	7%
Fever or chills	27%	3%	4%	4%
Systemic infections	4%	Not available	0.3%	Not available
Skin rash	6%	13%	2%	2%
Suppression of bone marrow activity	1%	2%	13%	0.8%

Recent studies have indicated a possible benefit of reducing recurrences by instilling these chemicals into the bladder immediately following resection of a bladder tumor, typically in the recovery room. BCG is not used in this way because of the risk that it might be absorbed into the bloodstream in this setting.
Once the grade and stage of the tumor has been determined, the urologist may decide to initiate a course of intravesical therapy with these agents. Generally, BCG is chosen if either stage T1 or carcinoma in situ is present. These patients are at highest risk of recurrence and progression and BCG is the most effective agent for preventing these adverse events. In general, Mitomycin is used for stage Ta tumors. Indications for these treatments are based upon the number of tumors that were present, their size, their appearance, the grade of tumor, and whether or not they penetrated the wall of the bladder (but not including the muscle layer). In general, six weekly treatments are given, in which a catheter is placed in the bladder, the medication is instilled, the catheter is removed, and the patient is instructed not to urinate for at least an hour.
Once the bladder has been assessed as free of disease at the first three month post-treatment cystoscopic inspection, many physicians consider it appropriate to apply additional treatments of these same drugs to forestall or prevent future recurrences.  While recent studies demonstrate this concept of  "maintenance therapy" is useful for some patients receiving BCG, it is of less certain benefit for those receiving the other three chemotherapeutic drugs. Whether additional treatments are given or not, periodic cystoscopies are required to detect tumor recurrence early, if it is going to develop. During the first one to two years surveillance is carried out on a quarterly basis but then can gradually be reduced to twice and eventually even once per year thereafter.
Cystectomy:  Surgical removal of the bladder may be an option for patients with CIS or high-grade T1 cancers that have persisted or recurred after initial intravesical treatment. There is a substantial risk of progression to muscle-invasive cancer in such cases, and some patients may want to consider cystectomy as a first choice of treatment. If so, they should ask their doctor for information about both the risks of cystectomy and the methods of urinary reconstruction ("urinary diversion").
An alternative is to repeat intravesical therapy. There is some evidence that patients may respond to repeat therapy. However, the evidence is too weak to draw firm conclusions about whether any amount or type of intravesical therapy, in any combination, can affect progression of high-grade disease. Patients with high risk disease, such as high grade TA or T1 cancer or CIS, who fail BCG are at particularly high risk and should strongly consider radical cystectomy.