Prognosis

In the US, the 5-year relative survival for bladder cancer is 78.4%.[17]​ Factors associated with poorer prognosis include older age, female sex, smoking, and higher stage at diagnosis.[13][134][135]

Most patients present with low-grade, nonmuscle-invasive bladder cancer (NMIBC). These patients are at high risk for tumor recurrence but low risk for disease progression and death. High-grade NMIBC, especially if invasive into the lamina propria or associated with carcinoma in situ (CIS), is a risk for both recurrence and progression.[1]

Once muscle invasion occurs, overall survival is in the range of 50% even with cystectomy.[1] Combination cisplatin-based chemotherapy produces frequent objective responses, but <10% of patients with metastatic disease are cured with current drugs.[136] The introduction of immunotherapy with immune-checkpoint inhibitors revolutionized the treatment of patients with metastatic bladder cancer, with some patients having durable responses with these agents.[137] Immune-checkpoint inhibitors can be particularly beneficial to older patients who may not be candidates for chemotherapy.[138]

Low-risk bladder cancer

Low-grade, solitary, noninvasive bladder cancer has a 15-year recurrence risk of 65%, but progression occurs in <5% of patients. Treatment with intravesical chemotherapy reduces the 2-year risk of recurrence by up to 20%.[139] The effect of intravesical chemotherapy is not repeated in patients with intermediate- or high-risk bladder cancer.[140]

Intermediate-risk bladder cancer

Large, multifocal, or recurrent low-grade Ta bladder cancer poses increased risk for both recurrence and progression. Without treatment, the risk of recurrence by 15 years approaches 90%. Intravesical chemotherapy reduces recurrence by up to 20% in the short term, but has little effect on long-term recurrence and has not been found to reduce progression. Bacille Calmette-Guérin (BCG) immunotherapy using 3-week maintenance, while more toxic than chemotherapy, significantly reduced recurrence, metastasis, and death from bladder cancer in one large randomized controlled trial.[141][142]

High-risk bladder cancer

CIS, high-grade, and T1 invasive bladder cancer is the most dangerous category of NMIBC, and carries a high risk of disease progression and death from bladder cancer. These patients are at about 50% risk for treatment failure and 15% risk of progression.[143] Patients at high risk of recurrence and/or progression do poorly on the currently recommended 1 to 3 years of maintenance BCG schedules, and alternative treatments are urgently required.[144] 

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