Bladder Cancer (PDQ®): Treatment

General Information

Note: Estimated new cases and deaths from bladder cancer in the United States in 2005:[1]

• New cases: 63,210.
• Deaths: 13,180.

Approximately 70% to 80% of patients with newly diagnosed bladder cancer will present with superficial bladder tumors (i.e., stage Ta, Tis, or T1). Those who do present with superficial, noninvasive bladder cancer can often be cured, and those with deeply invasive disease can sometimes be cured by surgery, irradiation, or a combination of modalities that include chemotherapy. Studies have demonstrated that some patients with distant metastases have achieved long-term complete response following treatment with combination chemotherapy regimens. There are clinical trials suitable for patients with all stages of bladder cancer; whenever possible, patients should be included in clinical trials designed to improve on standard therapy.

The major prognostic factors in carcinoma of the bladder are the depth of invasion into the bladder wall and the degree of differentiation of the tumor. Most superficial tumors are well differentiated. Patients in whom superficial tumors are less differentiated, large, multiple, or associated with carcinoma in situ (Tis) in other areas of the bladder mucosa are at greatest risk for recurrence and the development of invasive cancer. Such patients may be considered to have the entire urothelial surface at risk for the development of cancer. Tis may exist for variable durations. Adverse prognostic features associated with a greater risk of disease progression include the presence of multiple aneuploid cell lines, nuclear p53 overexpression, and expression of the Lewis-x blood group antigen.[2-5] Patients with Tis who have a complete response to bacillus Calmette-Guérin have approximately a 20% risk of disease progression at 5 years; patients with incomplete response have approximately a 95% risk of disease progression.[2] Several treatment methods (i.e., transurethral surgery, intravesical medications, and cystectomy) have been used in the management of patients with superficial tumors, and each method can be associated with 5-year survival in 55% to 80% of patients treated.[2,3,6]

Invasive tumors that are confined to the bladder muscle on pathologic staging after radical cystectomy are associated with approximately a 75% 5-year progression-free survival rate. Patients with more deeply invasive tumors, which are also usually less well differentiated, experience 5-year survival rates of 20% to 40% following radical cystectomy. When the patient presents with locally extensive tumor that invades pelvic viscera or with metastases to lymph nodes or distant sites, 5-year survival is uncommon, but considerable symptomatic palliation can still be achieved.[7]

Expression of the tumor suppressor gene p53 also has been associated with an adverse prognosis for patients with invasive bladder cancer. A retrospective study of 243 patients treated by radical cystectomy found that the presence of nuclear p53 was an independent predictor for recurrence among patients with stage T1, T2, or T3 tumors.[8] Another retrospective study showed p53 expression to be of prognostic value when considered with stage or labeling index.[9]

References

1. American Cancer Society.: Cancer Facts and Figures 2005. Atlanta, Ga: American Cancer Society, 2005. Also available online. Last accessed May 20, 2005. 
2. Hudson MA, Herr HW: Carcinoma in situ of the bladder. J Urol 153 (3 Pt 1): 564-72, 1995.  [PUBMED Abstract]
3. Torti FM, Lum BL: The biology and treatment of superficial bladder cancer. J Clin Oncol 2 (5): 505-31, 1984.  [PUBMED Abstract]
4. Lacombe L, Dalbagni G, Zhang ZF, et al.: Overexpression of p53 protein in a high-risk population of patients with superficial bladder cancer before and after bacillus Calmette-Guérin therapy: correlation to clinical outcome. J Clin Oncol 14 (10): 2646-52, 1996.  [PUBMED Abstract]
5. Stein JP, Grossfeld GD, Ginsberg DA, et al.: Prognostic markers in bladder cancer: a contemporary review of the literature. J Urol 160 (3 Pt 1): 645-59, 1998.  [PUBMED Abstract]
6. Witjes JA, Caris CT, Mungan NA, et al.: Results of a randomized phase III trial of sequential intravesical therapy with mitomycin C and bacillus Calmette-Guerin versus mitomycin C alone in patients with superficial bladder cancer. J Urol 160 (5): 1668-71; discussion 1671-2, 1998.  [PUBMED Abstract]
7. Thrasher JB, Crawford ED: Current management of invasive and metastatic transitional cell carcinoma of the bladder. J Urol 149 (5): 957-72, 1993.  [PUBMED Abstract]
8. Esrig D, Elmajian D, Groshen S, et al.: Accumulation of nuclear p53 and tumor progression in bladder cancer. N Engl J Med 331 (19): 1259-64, 1994.  [PUBMED Abstract]
9. Lipponen PK: Over-expression of p53 nuclear oncoprotein in transitional-cell bladder cancer and its prognostic value. Int J Cancer 53 (3): 365-70, 1993.  [PUBMED Abstract]

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