Bladder cancer

Visible blood in urine, sometimes without pain, is a common reason for investigation. Frequency or burning can also result from infection. Persistent or recurrent symptoms need assessment even when bleeding stops. Smoking and certain occupational exposures increase risk, but their absence does not exclude cancer.

Cystoscopy examines the bladder. Transurethral resection of bladder tumor (TURBT) provides tissue to establish type, grade and depth. Ask whether detrusor muscle is present in the specimen and whether resection was complete. T1/high-grade disease, incomplete removal or inadequate muscle sampling may require repeat TURBT, depending on the findings.

Most bladder cancers are urothelial carcinomas. Squamous, adenocarcinoma, small-cell/neuroendocrine and variant patterns may change treatment. Urine cytology and imaging complement tissue diagnosis. Renal pelvis and ureter tumors share the urothelial lining but have a different local-treatment pathway.

Non-muscle-invasive bladder cancer (NMIBC) includes Ta, T1 and carcinoma in situ (CIS). Grade describes cellular abnormality and helps estimate progression risk. Number, size, recurrence history, CIS and pathological features matter: a small low-grade Ta tumor and high-grade T1 with CIS need different plans.

After TURBT, lower-risk disease may receive an immediate postoperative chemotherapy instillation when safe, followed by surveillance. Intermediate-risk disease may need a course of intravesical chemotherapy or BCG. High-risk disease often calls for BCG induction and maintenance; very high-risk features warrant discussing early radical cystectomy.

BCG is an immune treatment placed inside the bladder through a catheter, different from intravenous checkpoint immunotherapy. A newer US-approved option combines durvalumab with BCG for adults with BCG-naive high-risk NMIBC. This initial-treatment indication is different from treatment after adequate BCG has failed.

BCG-unresponsive is a specific clinical category, not every recurrence after BCG. The team checks adequate prior exposure, high-grade disease or CIS, and the interval since treatment. Stopping because of intolerance is another situation. Bring the instillation record and subsequent cystoscopy and pathology reports.

Radical cystectomy is an important curative route for suitable patients with BCG-unresponsive high-risk disease. Bladder preservation needs a defined response-assessment timetable and a surgery plan if cancer persists or progresses. Repeatedly changing bladder treatments can lose a window for effective surgery.

These options are not automatically interchangeable. Their CIS-based indications should not be extended to papillary-only disease without checking the evidence and local authorization.

For disease suitable for curative local treatment, radical cystectomy removes the bladder with regional lymph-node assessment and creates a new route for urine. A multidisciplinary team considers treatment before and after surgery, fitness, kidney function and tumor characteristics.

Selected patients can consider trimodality therapy: maximal TURBT followed by radiotherapy with a radiosensitizing drug. Selection considers tumor extent, bladder function, hydronephrosis, CIS and patient preference. Repeated cystoscopy and access to salvage cystectomy are essential. TURBT alone is not equivalent to this complete approach.

Cisplatin-based combination chemotherapy before cystectomy is an established option for eligible patients. Eligibility depends on kidney function, hearing, neuropathy, cardiac status and fitness, not age alone. Carboplatin is not an automatic equivalent replacement in a curative neoadjuvant plan.

Current US perioperative options include durvalumab with gemcitabine/cisplatin before surgery followed by durvalumab afterward, and enfortumab vedotin with pembrolizumab before and after cystectomy for adults with MIBC. The current enfortumab combination indication is not restricted in its indication text to cisplatin-ineligible patients. These are distinct pathways; their components should not simply be stacked together.

After surgery, pathological stage, nodal involvement and previous treatment guide discussion of additional chemotherapy or immunotherapy. A regimen studied starting before surgery cannot automatically be used as an identical postoperative-only plan.

Systemic treatment aims to control disease, relieve symptoms and extend life. Enfortumab vedotin plus pembrolizumab is US-approved for adults with locally advanced or metastatic urothelial cancer. Diabetes, neuropathy, skin disease, organ function and prior immunotherapy affect suitability; this combination does not require selection by PD-L1 level.

Another pathway uses platinum chemotherapy followed by avelumab maintenance when disease has not progressed. Maintenance is different from treating progression and is not automatically added after every modern first-line combination. Later choices depend on prior drugs, response duration, biomarkers and trials.

In the United States, erdafitinib is indicated for adults with locally advanced or metastatic urothelial cancer with susceptible FGFR3 alterations after at least one systemic treatment. It is not recommended before PD-1/PD-L1 therapy for eligible patients who have not received those drugs. The current indication is FGFR3-specific; an old reference to FGFR2 is insufficient.

The US tumor-agnostic accelerated indication for trastuzumab deruxtecan covers adults with unresectable or metastatic HER2-positive (IHC 3+) solid tumors after prior systemic treatment when no satisfactory alternative exists. A gene alteration alone does not establish this IHC-based eligibility. MSI/MMR and other results may identify additional options in their specific settings.

Before cystectomy, discuss an ileal conduit with a stoma, a continent reservoir or a neobladder where suitable. Daily care, continence and catheter needs differ. A neobladder is not suitable for everyone and does not guarantee normal urination. Discuss sexual function, fertility and stoma education before surgery.

Seek prompt advice for fever or serious illness after BCG, inability to urinate, heavy bleeding or clots. During systemic therapy, new severe rash, breathlessness or marked thirst and weakness need rapid assessment. Enfortumab can cause serious skin reactions, hyperglycemia and neuropathy; erdafitinib requires eye and phosphate monitoring; trastuzumab deruxtecan can cause interstitial lung disease.

After bladder preservation, follow-up can include cystoscopy, urine tests and upper-tract imaging according to risk. After cystectomy, monitoring also covers kidney function and urinary diversion. A negative scan does not replace cystoscopy when direct bladder surveillance is needed.

• Bring pathology including muscle sampling, grade, CIS and variant histology.
• List each BCG instillation and other bladder treatment, with dates and subsequent findings.
• Include imaging, kidney-function results, prior systemic treatments and biomarker reports.
• Ask what would trigger changing from bladder preservation to surgery and who will oversee follow-up.