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Walk to End Bladder Cancer

What is Non-Muscle Invasive Bladder Cancer?

Non-muscle invasive bladder cancer, sometimes called NMIBC, is when the tumor has not grown into the thicker muscle wall of the bladder.  Roughly 70% of bladder cancer is found in the tissue (called urothelial or transitional cells) that line the inside of the bladder. The tumor has not grown into the thicker muscle wall of the bladder.

How is non-muscle invasive bladder cancer treated?

Non-muscle invasive bladder cancer is usually treated by a Transurethral Resection of the Bladder Tumor (TURBT) to remove the tumor. Once the tumor is removed, a pathologist will look at the cells under a microscope. They want to see how aggressive the cells are in the tumor, and they give them a grade that helps doctors know the risk that the cancer will:

  • Come back (recurrence): After treatment, a new tumor grows in the bladder.
  • Get worse (progression): The cancer grows deeper into the bladder wall or spreads to other parts of the body.

Cells that look more like normal bladder cells, usually grow slowly and are less likely to spread. They are called low-grade.

Cells that look very abnormal, grow quickly and are more likely to come back or get worse are high-grade.

Doctors group NMIBC into low, intermediate, or high risk based on:

  • Tumor grade (how abnormal the cells look),
  • Stage (how deep the cancer grows in the bladder),
  • Tumor size and number of tumors, and
  • Whether it comes back.

Low-risk cancers are usually low-grade, small, and not likely to come back or spread. Intermediate-risk cancers are more serious than low risk but not as aggressive as high risk; they may include low- or high-grade tumors that are larger, come back after treatment, involve more than one tumor, or keep returning.

High-risk cancers are often high-grade, may have invaded the bladder lining more deeply, and need stronger treatment with very close follow-up. The doctor will recommend the right treatment based on risk:

  • Low-risk (low grade): surgery with TURBT (tumor removal) may be enough.
  • Intermediate-risk (can be low grade or high grade/depends on stage): surgery + possible medicine in the bladder.
  • High-risk (high grade): stronger treatments with more aggressive medicines in the bladder and sometimes even bladder removal.

Knowing the risk can also help the doctors plan follow-up care and monitoring for signs the bladder cancer has returned:

  • Low risk: fewer check-ups.
  • Intermediate risk: more frequent check-ups.
  • High risk: very close monitoring.

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How is low-grade non-muscle invasive bladder cancer treated?

Non-muscle invasive bladder cancer is usually treated by a Transurethral Resection of the Bladder Tumor (TURBT) to remove the tumor. Once the tumor is removed, your doctor may suggest putting medicine in the bladder to reduce the risk of the cancer returning. That is known as intravesical therapy.  For low grade cancers this is often a chemotherapy.  Remember this goes directly into the bladder by a catheter and does not go through veins like traditional chemotherapy. 

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How is intermediate-grade non-muscle invasive bladder cancer treated?

ZUSDURI is a treatment for people with low-grade, intermediate-risk bladder cancer that has come back but has not spread into the bladder wall. The medicine goes into the bladder as a liquid through a thin tube (catheter). Once inside, it warms to body temperature and becomes a gel. The gel slowly releases the cancer medicine (mitomycin) for about 5 hours, sometimes up to 24 hours, and then leaves the body when you urinate. This chemotherapy is put into the bladder once a week for 6 weeks for patients with low grade recurrent NMIBC. You go home the same day after treatment. It is done in an office setting without any surgery or anesthesia.  It is very important to follow your doctor’s instructions and avoid having urine touching your skin for at least 24 hours. Common side effects include pain or burning when you pee, bladder infection, blood in the urine, and changes in blood tests.

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How is high-grade non-muscle invasive bladder cancer treated?

Bacille Calmette-Guerin (BCG) is the gold standard for treating NMIBC. BCG is a weakened type of tuberculosis that is given in the bladder through a catheter. It activates your immune system to attack the abnormal bladder lining. It works well for high grade tumors and carcinoma in situ. Usually, doctors wait to give BCG for about four to six weeks after your bladder biopsy, or TURBT, because the bladder wall needs to be healed.

BCG is usually administered once a week for six weeks. After that six weeks doctors look in the bladder to see if the treatments were effective. If your bladder cancer has not returned after the initial 6 treatments with BCG then it is recommended to continue getting BCG therapy for a maintenance regimen that is usually an additional 3 doses (3 weeks in a row) every 3 to 6 months for 1-3 years in total. 

BCG is the standard treatment and can work very well. Unfortunately despite adequate treatment with BCG, sometimes high-risk bladder cancer recurs.  The option for bladder removal is always there but now there are some more bladder-based therapies that can be used.  There are many approved options if this happens. 

ANKTIVA® is an immunotherapy medicine used with BCG for people with bladder cancer that has not responded to BCG alone (called BCG-unresponsive non-muscle invasive bladder cancer with carcinoma in situ, or CIS). It works by activating natural killer (NK) cells, which are part of your immune system, to find and kill bladder cancer cells. The medicine is given directly into your bladder through a thin tube (catheter), just like BCG. Recovery time is similar to BCG treatment. ANKTIVA is always given together with BCG. Because BCG is sometimes hard to get, the company that makes ANKTIVA is also working on new types of BCG to help more patients in the future.  The schedule for ANKTIVA is similar to the induction and maintenance schedule of BCG alone. 

Adstiladrin is a gene-based therapy for adults with non-muscle invasive bladder cancer (NMIBC) who no longer respond to BCG treatment. It is used for patients whose cancer persists after BCG or comes back after initially being tumor-free. The medicine is a liquid that is put directly into the bladder through a thin tube (catheter). It contains a virus that carries a gene to make interferon alfa-2b, a natural protein that helps the body/bladder fight cancer. The virus works in the bladder cells to boost the immune system and does not change your DNA. The treatment is usually given once every three months in the doctor’s office.

INLEXZO TM (gemcitabine intravesical system) is a small device the doctor places inside your bladder using a catheter through your urethra. The device slowly releases a chemotherapy medicine called gemcitabine over about 3 weeks-which is how long this small device stays in the bladder where the cancer was located.  This means the medicine stays in your bladder longer to fight the cancer cells, while lowering the amount that goes to the rest of your body. INLEXZO is an option for some people whose cancer did not get better with BCG and who cannot, or choose not to, have surgery to remove the bladder.

What happens if medicines put into the bladder (like BCG, ANKTIVA, Adstiladrin, INLEXZO or Zusduri) do not control the cancer?

The main treatment option is surgery to remove the bladder (called a cystectomy). Removing the bladder gives the best chance of getting rid of the cancer completely before it spreads into the bladder muscle or to other parts of the body.

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Podcasts about NMIBC treatment

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Read stories from non-muscle invasive bladder cancer patients

You can also learn more about the treatment options for all stages of bladder cancer.

What does carcinoma in situ mean?

Carcinoma in situ (CIS) is a cancerous patch of bladder lining, often referred to as a “flat tumor.” The patch may look almost normal or may look red and inflamed. CIS is a type of non muscle-invasive bladder cancer that is of higher grade and increases the risk of recurrence and progression. At diagnosis, approximately 10% of patients with bladder cancer present with CIS.

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Webinar: Explanation of Non-muscle Invasive Bladder Cancer

Part 1: Understanding Types and Stages of Non-muscle Invasive Bladder Cancer

Transcript (PDF)

Part 2: Understanding Treatments for Non-muscle Invasive Bladder Cancer

Transcript (PDF)

Part 3: Question and Answer about Non Muscle Invasive Bladder Cancer

Transcript (PDF)

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Resources for non-muscle invasive bladder cancer patients

Podcasts with information about NMIBC:

This “Bladder Cancer Matters” podcast offers additional information about NMIBC:

Additonal webinars with information about NMIBC:

BCAN webinars are online, recorded conversations with medical experts. We offer several Patient Insight Webinars with about information about non-muscle invasive bladder cancer, including:

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