Bladder Cancer Treatment by Stage: BCG, Immunotherapy and Surgery Explained

Staging and Treatment Decisions

Bladder cancer treatment depends on whether the disease is non–muscle invasive or muscle-invasive, a distinction that “is very important,” according to Dr. David Greenberg, FACP Section Chief, Hematology Oncology, Hackensack Meridian Jersey Shore University Medical Center. This classification is typically determined after a transurethral resection of the bladder tumor (TURBT), a procedure used to remove and evaluate the tumor. Non–muscle invasive disease is typically associated with a strong prognosis and is most often treated with local therapies such as tumor removal followed by intravesical treatment with BCG, which is delivered directly into the bladder to eliminate remaining cancer cells. In contrast, muscle-invasive bladder cancer signals a deeper level of tumor penetration into the bladder wall and a higher likelihood of spread, requiring more aggressive treatment, often including systemic chemotherapy, immunotherapy and bladder removal to achieve a cure.

“How extensive the tumor is and whether or not it’s invading the muscle…really determines the prognosis,” Dr. Greenberg explains. He notes that once cancer reaches the muscle layer, local therapies alone are no longer sufficient because of the increased risk of microscopic spread beyond the bladder. BCG works by triggering an immune response within the bladder to attack residual cancer cells, and “time is really the only thing [that] will tell us that the BCG is working,” he adds, emphasizing the importance of repeated cystoscopies and close follow-up. When BCG fails or when the cancer invades the muscle, cystectomy becomes necessary, typically after pre-surgical systemic treatment such as chemotherapy or chemoimmunotherapy to shrink the tumor, reduce disease burden and improve surgical outcomes.

Quality of Life, Advances and Follow-Up

Treatment can significantly affect urinary function and overall quality of life, with some patients experiencing symptoms such as frequent urination, urgency, discomfort or bladder irritation due to therapy. “Patients may be urinating frequently, sometimes every hour on the hour,” Dr. Greenberg notes, highlighting how disruptive these symptoms can be. For those who undergo bladder removal, reconstruction options include a neobladder, which is surgically created using intestinal tissue and can mimic more natural urinary function over time, or an ileal conduit, which diverts urine to an external bag. Each option comes with different physical and lifestyle considerations, and “it really depends on the patient,” he says, emphasizing the importance of individualized decision-making.

Advances in immunotherapy, particularly with agents like pembrolizumab, have been “a game changer,” especially for patients who do not respond to BCG and may be able to avoid surgery altogether. In addition, treatment standards for muscle-invasive disease continue to evolve, with immunotherapy now being combined with chemotherapy prior to bladder removal, leading to improved response rates, more successful surgeries and better long-term outcomes. Beyond immunotherapy, emerging targeted therapies and genomic testing are helping identify mutations that may guide more personalized treatment approaches.

After treatment, close monitoring remains critical, particularly in the first two to three years when most recurrences occur. Dr. Greenberg notes that the majority of cancers recur within this window, making intensive surveillance essential early on. Follow-up typically includes regular imaging such as CT or PET scans, as well as cystoscopy for patients who retain their bladder. Over time, the frequency of monitoring may decrease, particularly after five years. Emerging tools such as circulating tumor DNA (ctDNA) testing are also being explored to detect microscopic disease in the blood, offering an additional layer of insight into whether cancer may still be present. While still evolving, these tools may help refine surveillance strategies and provide reassurance for patients moving forward.

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