Bladder Cancer
Summary of Key Points
Incidence
• Worldwide, bladder cancer is diagnosed in approximately 380,300 cases each year and causes 150,200 deaths. In the United States, it is the sixth most common cancer, with an estimated 73,510 diagnoses and 13,750 deaths in 2012.
• Median age at diagnosis is 73 to 74 years. Many patients have comorbid illnesses such as cardiovascular disease at diagnosis.
• Cigarette smoking is the most significant risk factor, accounting for approximately 50% of bladder cancers in the United States. Occupational chemical exposure to polycyclic aromatic hydrocarbons and aromatic amines represents the next most important risk factor.
Staging Evaluation
• There is no clear role for screening.
• The primary manifesting symptom is painless gross hematuria. All patients with unexplained gross hematuria require evaluation.
• Cystoscopy with transurethral resection and urine cytology are the mainstay of diagnosis. Photodetection during cystoscopy is increasingly used to improve sensitivity of detecting bladder tumors.
• Upper tract evaluation is necessary to detect additional urothelial tumors and obstruction.
• Patients with muscle-invasive bladder cancer (MIBC) require metastatic workup.
Primary Therapy
• Transurethral resection of bladder tumor (TURBT) is the initial procedure and used to determine the clinical stage that drives subsequent treatment approaches.
• For patients with noninvasive bladder cancer (Ta, Tis, or T1), a complete TURBT may be sufficient. The addition of intravesical therapy reduces the risks of recurrence and progression to muscle-invasive cancer.
• Bacillus Calmette-Guerin (BCG) is the most effective agent for intravesical therapy in patients with high-grade noninvasive disease. An induction course of 6-weekly treatments, followed by maintenance therapy every 6 months for 2 to 3 years, may be used.
• For patients with MIBC, radical cystectomy with urinary diversion is the most commonly used treatment approach in the United States. However, there is significant undertreatment of elderly patients with MIBC likely because of concerns about tolerability of cystectomy.
• Trimodality bladder preservation therapy (TURBT followed by concurrent chemoradiation) is a well-tolerated and effective alternative for patients with MIBC, including elderly patients. Overall, 75% to 80% of patients maintain their native bladders long-term.
• Effective radiosensitizing chemotherapy agents include cisplatin-based regimens or 5-fluorouracil (5-FU) with mitomycin C.
Neoadjuvant and Adjuvant Therapy
• Despite aggressive local treatment, up to 50% of MIBC patients eventually develop local or distant recurrences.
• Neoadjuvant cisplatin-based chemotherapy prior to cystectomy provides a 5% to 10% absolute benefit in overall survival over cystectomy alone.
• Data on the potential benefit of adjuvant chemotherapy are conflicting, and treatment decisions should be individualized.
