Prognosis

In the US, the 5-year relative survival for bladder cancer is 79% (based on 2014-2021 data).[15] But survival varies considerably based on stage at diagnosis:[15]

  • In situ: 97.9%

  • Localised: 72.6%

  • Regional: 40.5%

  • Distant metastases: 9.1%

Most patients are diagnosed with in situ (50%) or localised bladder cancer (34%). Approximately 7% have regional spread to the lymph nodes at diagnosis, and 6% have distant metastases at diagnosis.[15]

Additional factors associated with poorer prognosis include older age, female sex, and smoking.[13][167][168]​​​ 

Certain histological subtypes, such as micropapillary, plasmacytoid, sarcomatoid, and neuroendocrine subtypes, are associated with a higher risk of progression and recurrence.[169][170][171]​​​​ Other unfavourable pathological features in non-muscle-invasive bladder cancer include presence of carcinoma in situ (CIS), lymphovascular invasion, multifocal tumours, residual tumour, or incomplete resection.[21]

Low-risk non-muscle-invasive bladder cancer

Low-grade, solitary, non-invasive bladder cancer has a 15-year recurrence risk of 65%, but progression occurs in <5% of patients. Treatment with immediate intravesical chemotherapy reduces the 2-year risk of recurrence by up to 20%.[172] The effect of intravesical chemotherapy is not repeated in patients with intermediate- or high-risk bladder cancer.[173]

Intermediate-risk non-muscle-invasive bladder cancer

Large, multifocal, or recurrent low-grade Ta bladder cancer increases risk for both recurrence and progression. Intravesical chemotherapy reduces recurrence by up to 20% in the short term, but has not been found to reduce progression. Bacillus Calmette-Guérin (BCG), while more toxic than chemotherapy, decreased risk of recurrence in trials that included BCG maintenance regimens.[95]​​[174]

High-risk non-muscle-invasive bladder cancer

CIS, high-grade, and T1 invasive bladder cancer carries a high risk of disease progression and death from bladder cancer. Patients at high risk of recurrence and/or progression do poorly on recommended maintenance BCG schedules of 3 years.[175]

Muscle-invasive bladder cancer

Once muscle invasion occurs, overall survival is approximately 50% even with cystectomy.[1]​ Combination cisplatin-based chemotherapy produces frequent objective responses, but <10% of patients with metastatic disease are cured with chemotherapy.[176] The introduction of immunotherapy with immune-checkpoint inhibitors has considerably improved treatment of patients with metastatic bladder cancer, with some patients having durable responses with these agents.[177]​ Immune-checkpoint inhibitors can be particularly beneficial to older patients who may not be candidates for chemotherapy.[178]

Without treatment, muscle-invasive tumours cause increasingly severe local symptoms, with death from metastatic disease likely within 2 years.[179][180][181]​ Patients are often elderly and may have a high comorbidity burden, however treatment with curative intent should always be considered in preference to palliation for patients with muscle-invasive tumours. 

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