FIG. 5:  T1 bladder cancer is an aggressive disease.  Patients not treated with bacillus Calmette-Guérin (BCG) – up to 60%, based on data from pre-BCG era patients – experience disease progression to muscle-invasive disease.  Today, in the BCG era, despite the best care administered to these patients, up to 30–40% of these patients will experience disease progression and eventual death from the cancer.^[3,4] 

Because T1 bladder cancer has early access to the lymphatic and vascular systems, approximately 18% of clinical cases are estimated to already have lymph node metastases.  The most important reason for this is prior understaging. 

From pathologically confirmed T1 (after radical cystectomy), approximately 7% of patients already have lymph node metastases, showing the early propensity of this disease to spread.^[5]  The major issue in dealing with T1 certainly comes from the difficulty in staging it appropriately.  Somewhere between 30% to 60% of patients who are thought to be T1 end up to be a T2 cancer, ie, muscle-invasive on radical cystectomy.^[7]  The key question is how to identify the patients who will fail current conservative management and those who will actually not have a chance to respond at all, and to respond to them not with an early, but with an immediate radical cystectomy.