Bladder Cancer Treatment (PDQ®): Treatment - Health Professional Information [NCI] - Stage I Bladder Cancer
Stage I bladder cancer is defined by the following TNM classification:
T1, N0, M0
Patients with stage I bladder tumors can be cured by a variety of treatments, even though the tendency for new tumor formation is high. In a series of patients with Ta or T1 tumors who were followed for a minimum of 20 years or until death, the risk of bladder recurrence following initial resection was 80%. Patients at greatest risk of recurrent disease are those whose tumors are large, poorly differentiated, multiple, or associated with nuclear p53 overexpression. In addition, patients with carcinomain situ (Tis) or dysplasia of grossly uninvolved bladder epithelium are at greater risk of recurrence and progression.[1,3,4]
In its early stages, bladder cancer may not have obvious symptoms. In the later stages, symptoms of bladder cancer may include:
Bloody urine, most often painless, is the most common symptom. The urine color ranges from faintly rusty to deep red, sometimes containing blood clots. Blood traces, invisible to the naked eye, may show up in tests of urine samples.
Frequent urinary tract infections, painful urination, a need to urinate often, and difficulty holding in urine.
Transurethral resection (TUR) and fulguration are the most common and conservative forms of management. Careful surveillance of subsequent bladder tumor progression is important. One retrospective series addressed the value of performing a second TUR within 2 to 6 weeks of the first.[Level of evidence: 3iiDiv] A second TUR performed on 58 patients with T1 disease found that 14 patients (24%) had residual (T1) disease and 16 patients (28%) had muscle invasion (T2). Such information may change the definitive management options in these individuals.
Patients who require more aggressive forms of treatment are those with extensive multifocal recurrent disease and/or other unfavorable prognostic features. Segmental cystectomy is applicable to only a small minority of patients because of the tendency of bladder carcinoma to involve multiple regions of the bladder mucosa and to occur in areas that cannot be segmentally resected.
Intravesical therapy with thiotepa, mitomycin, doxorubicin, or bacillus Calmette Guérin (BCG) is most often used in patients with multiple tumors or recurrent tumors or as a prophylactic measure in high-risk patients after TUR. Administration of intravesical BCG combined with subcutaneous BCG following TUR was compared with TUR alone in patients with Ta and T1 lesions. Treatment with BCG delayed progression to muscle-invasive and/or metastatic disease, improved bladder preservation, and decreased the risk of death from bladder cancer.[6,7]
A randomized study of patients with superficial bladder cancer also reported a decrease in tumor recurrence in patients given intravesical and percutaneous BCG compared with controls. Two, nonconsecutive, 6-week courses with BCG may be necessary to obtain optimal response. Patients with a T1 tumor at the 3-month evaluation after a 6-week course of BCG and patients with Tis that persists after a second 6-week BCG course have a high likelihood of developing muscle-invasive disease and should be considered for cystectomy.[9,10,11] A randomized study that compared intravesical and subcutaneous BCG to intravesical doxorubicin showed better response rates and freedom from recurrence with the BCG regimen for recurrent papillary tumors as well as for Tis. Preliminary results of one study have shown a possible survival benefit with maintenance BCG after a 6-week induction course. Another study that compared alternating mitomycin and BCG with BCG alone, both given for 24 months, found that the efficacy was equal, but that the side effects of the combined regimen were slightly less.[Level of evidence: 1iiDiii] A similar trial comparing sequential mitomycin and BCG to mitomycin alone also found no major differences in toxic effects or efficacy.[Level of evidence: 1iiDiii] A randomized trial from the Swedish-Norwegian Bladder Cancer Group compared 2 years of intravesical treatment with mitomycin C versus BCG for patients at high risk for recurrence or progression. At 5 years, a significant improvement was noted in disease-free survival with BCG (P = .04); however, no difference was observed in tumor progression or overall survival between the two arms.