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Management of Advanced Bladder Cancer: What You Should Know

What You Should Know About Treatment of Advanced Bladder Cancer

This article is for people who have advanced bladder cancer or anyone who wants to learn more about advanced bladder cancer. The goal of this patient education activity is to make patients more aware of available treatment options for advanced bladder cancer.

You will learn:

  • What chemotherapy is and how it is used to treat advanced bladder cancer

  • What checkpoint inhibitors are and how they are used to treat advanced bladder cancer

  • The potential side effects of chemotherapy and checkpoint inhibitors

  • Why the side effects from chemotherapy and checkpoint inhibitors are different

  • Questions to ask your doctor

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How Is Bladder Cancer Treated?

Bladder cancer is treated in several ways:

  • Traditional ways include surgery, radiation therapy, and chemotherapy

  • A newer treatment is immunotherapy, using medicines called checkpoint inhibitors

What Is Chemotherapy?

Chemotherapy uses medicines to stop cancer cells from growing and dividing.

Chemotherapy for advanced bladder cancer includes:

  • Cisplatin (Platinol®) plus gemcitabine (Gemzar®)

  • Carboplatin (Paraplatin®) plus gemcitabine

  • MVAC (four medicines): methotrexate, vinblastine (Velban®, Velsar®), doxorubicin (Adriamycin®), and cisplatin

What Is a Checkpoint Inhibitor?

A checkpoint inhibitor is a medicine that boosts your body's natural immune system to fight cancer.

Checkpoint inhibitors are used for advanced forms of bladder cancer, which occur when the cancer has spread outside the bladder, either to the lymph nodes or to other parts of the body.

The first medicine you receive for your disease is called first-line treatment. Checkpoint inhibitors approved as first-line treatment for advanced bladder cancer are:

  • Atezolizumab (Tecentriq®)

  • Pembrolizumab (Keytruda®)

You will need a PD-L1 test first before your doctor can recommend a checkpoint inhibitor for first-line treatment.

What If First-Line Treatment Doesn't Work?

If the first medicine -- your first-line treatment -- doesn't work or stops working, you may need another treatment. This next treatment is called second-line treatment.

Checkpoint inhibitors approved for the second-line treatment of advanced bladder cancer are:

  • Atezolizumab (Tecentriq®)

  • Avelumab (Bavencio®)

  • Durvalumab (Imfinzi®)

  • Nivolumab (Opdivo®)

  • Pembrolizumab (Keytruda®)

You do not need a PD-L1 test to receive these checkpoint inhibitors as a second-line treatment.

Dr Arjun Balar discusses first-line and second-line treatments for advanced bladder cancer.

What You Should Know About Side Effects

In general, immunotherapy is better tolerated than chemotherapy.

The side effects of chemotherapy depend on the person and the dose used, but can include fatigue, infection, nausea, vomiting, hair loss, poor appetite, and diarrhea. Common side effects of checkpoint inhibitors include rash, diarrhea, low thyroid hormone, and fatigue.

Other side effects of the medicines are different.

Do Different Treatments Have Different Side Effects?

Yes. This is because checkpoint inhibitors do not work the same as chemotherapy -- they boost the immune system instead of killing cells.

Side effects from checkpoint inhibitors are caused by the boosted immune system and can occur in any organ. They include inflammation of the lungs, intestines, or liver; hormonal problems; and kidney, heart, or neurologic problems. Some side effects can be very serious and even life-threatening.

It is very important to contact your doctor immediately if you are having difficulty breathing. You should tell your doctor right away if you have a new side effect.

Dr Arjun Balar explains the differences in side effects from chemotherapy vs side effects from immunotherapy.

Which Type of Treatment Is Right for You?

The type of treatment that is best for you depends on several factors:

  • Results of your PD-L1 test

  • Whether it is first-line or second-line treatment

  • Your age

  • Other health conditions you have, like kidney damage

  • How much your cancer has spread (the stage of your cancer)

Questions You Should Ask Your Doctor

  • What stage is my bladder cancer? Has it spread?

  • Can my bladder cancer be treated?

  • What type of treatment is right for me?

  • What are the side effects of the treatment?

  • What's the difference between first-line and second-line treatment?

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Authors and Disclosures


Arjun Balar, MD

Associate Professor of MedicineDirectorGenitourinary Medical Oncology ProgramNYU Perlmutter Cancer CenterNew York, NY

Disclosure: Arjun Balar, MD, has disclosed the following relevant financial relationships:Served as an advisor or consultant for: AstraZeneca Pharmaceuticals LP; Genentech, Inc.; Merck & Co., Inc.; Pfizer Inc.; RocheReceived grants for clinical research from: AstraZeneca Pharmaceuticals LP; Bristol-Myers Squibb Company; Genentech, Inc.; Merck & Co., Inc.

Clinician Reviewer

Susan L. Smith, MN, PhD

Senior Scientific Director, Medscape, LLC 

Disclosure: Susan L. Smith, MN, PhD, has disclosed no relevant financial relationships.


Heather Lewin, MAT

Associate Scientific Director, Medscape, LLC

Disclosure: Heather Lewin, MAT, has disclosed no relevant financial relationships.

Vandana Iyer, PhD

Associate Scientific Director, Medscape, LLC

Disclosure: Vandana Iyer, PhD, has disclosed no relevant financial relationships.


Donald Hannaford

Medical Writer, Rumson, New Jersey

Disclosure: Donald Hannaford has disclosed no relevant financial relationships.


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