Introduction
Bladder cancer imposes a substantial and growing burden on China's health system, with approximately 75% of newly diagnosed cases presenting as non-muscle-invasive disease (NMIBC) and the remainder as muscle-invasive or advanced disease (MIBC) 17. Despite active guideline development — including the December 2025 Expert Consensus on Intravesical Therapy for NMIBC and the November 2024 Bladder-Preservation Multidisciplinary Therapy Consensus — a persistent and widening gap separates recommended care from real-world practice across Chinese healthcare settings 1720. This review synthesizes current evidence to characterize the most clinically consequential unmet needs for practising urologists and oncologists managing bladder cancer in China.
1. BCG Shortage and Its Impact on High-Risk NMIBC Care
Bacillus Calmette-Guérin (BCG) intravesical immunotherapy remains the cornerstone of management for high-risk NMIBC following transurethral resection of bladder tumour (TURBT). Guideline-concordant care requires induction therapy (6 weekly instillations) followed by maintenance treatment for up to 3 years, a schedule that meaningfully reduces recurrence and delays progression to muscle-invasive disease 517. In China, chronic BCG supply scarcity — driven by limited domestic manufacturing capacity and global supply constraints — renders this standard practically unachievable for many patients.
The clinical consequences of BCG shortage are not theoretical. A Korean single-centre retrospective study of 333 BCG-naive high-risk NMIBC patients documented 11 shortage episodes during the study period. Patients affected by shortage had a 3-year recurrence-free survival of only 38.0%, compared with 60.2% in the non-shortage group (log-rank P = 0.010), and BCG shortage was an independent predictor of recurrence in multivariable analysis (HR 1.55; 95% CI 1.09–2.21) 12. During shortage periods, only 28.7% of patients received BCG induction or maintenance, versus 68.1% in non-shortage periods; mitomycin C or epirubicin substitution rose from 1.7% to 27.7% 12. Although this evidence is from South Korea, it represents direct, quantifiable data on how supply disruption translates into measurably worse oncological outcomes — a pattern plausibly as severe or worse in China given additional infrastructure and reimbursement barriers.
The 2025 Chinese NMIBC consensus acknowledges the shortage explicitly and recommends pragmatic adaptation: high-risk patients should be prioritised for full-dose BCG induction, while maintenance may be compressed to a 1-year schedule under constrained supply; intermediate-risk patients may substitute chemotherapy-based intravesical therapy 1718. Patients with BCG-refractory carcinoma in situ — the highest-risk sub-group, for whom BCG is the only proven effective intravesical agent — are particularly vulnerable when supply fails, as no validated salvage intravesical option currently exists 617.
2. Intravesical Chemotherapy: Access, Variation, and Institutional Inequity
Beyond BCG, the delivery of guideline-concordant intravesical chemotherapy across Chinese care settings is inconsistent. Single-dose immediate intravesical chemotherapy within 24 hours of TURBT reduces 5-year recurrence by approximately 35%, yet institutional protocols for same-day instillation are not universal, and reimbursement coverage for intravesical agents across China's three insurance schemes (UEBMI, URBMI, NRCMS) is incomplete 114. The result is a de facto two-tier system: patients at urban tertiary centres with dedicated urology pharmacy support receive more complete intravesical regimens, while patients at secondary and community hospitals default to no maintenance therapy or sub-therapeutic courses 1.
Advanced intravesical delivery technologies — chemohyperthermia and electromotive drug administration (EMDA), which have shown improved efficacy in selected studies compared with standard instillation — require specialised equipment and trained personnel that are concentrated in major academic centres 1314. Rural hospitals lack both the technology and the expertise. Under BCG shortage conditions, expert consensus recommends chemohyperthermia with mitomycin C as the preferred alternative, yet this is precisely the option least available to the patients who most need it 14.
A small real-world Chinese study from Xijing Hospital (n = 21 HR-NMIBC patients) demonstrated that tislelizumab (anti-PD-1) plus BCG, with or without gemcitabine/cisplatin, yielded a 2-year bladder recurrence-free survival of 78.64% and a manageable safety profile 24. While promising, this combination approach requires access to checkpoint inhibitors and systemic chemotherapy, and its broader applicability across Chinese care settings — particularly rural or lower-tier institutions — remains entirely unstudied. The novelty of such regimens also means they are not yet standardised in national guidance.
3. MIBC Definitive Surgery: Cystectomy Access, Quality, and Perioperative Outcomes
Radical cystectomy with pelvic lymphadenectomy and neoadjuvant cisplatin-based chemotherapy (NAC) is the internationally endorsed standard for muscle-invasive, non-metastatic bladder cancer. Yet only approximately one-fifth of MIBC patients in China currently undergo surgery, reflecting substantial undertreatment driven by referral delays, patient refusal, surgical capacity constraints, and inadequate multidisciplinary coordination 2.
A Chinese Bladder Cancer Consortium study of 2,098 patients across 13 high-volume centres demonstrated acceptable oncological equivalence between minimally invasive and open radical cystectomy, with no significant differences in overall or cancer-specific survival (p = 0.653 and p = 0.816, respectively) 3. However, the study's restriction to 13 high-volume tertiary centres highlights that its findings are not representative of the broader Chinese landscape, where most patients receive care in lower-volume settings. International data from the National Cancer Database (2004–2020) quantify the magnitude of this volume-outcome gap: patients treated at high-volume centres had a 5-year overall survival of 37.7% versus 30.1% at low-volume centres (P < 0.001), with high-volume centre access also associated with higher rates of radical cystectomy (OR 1.67) and neoadjuvant chemotherapy receipt (OR 1.76), and lower readmission rates (OR 0.78) 15. Given that surgical expertise and robotic-assisted cystectomy capacity in China are concentrated in major urban centres, this volume-outcome gap represents a directly applicable and quantifiable source of preventable mortality 19.
NAC underutilisation compounds the cystectomy access problem. Cisplatin-based NAC (GC, ddMVAC, or CMV regimens) provides a 5–8% absolute 5-year survival benefit and reduces mortality risk by 10–13%, yet many Chinese patients are denied this benefit because of concerns about cisplatin toxicity, lack of formal geriatric or renal function assessment, or cost barriers 6. Carboplatin substitution — not guideline-endorsed and associated with pathological complete response rates of only 9.4% versus 36–42% with cisplatin — is used in some centres when cisplatin is perceived as too toxic, further compromising outcomes 6. Real-world data from a Greek multidisciplinary tumour board illustrate an additional, often overlooked problem: 27% of MIBC patients decline surgery after completing NAC 26, a phenomenon likely magnified in China given cultural attitudes toward cystectomy and quality-of-life concerns, though China-specific data on surgery refusal rates are currently unavailable.
Perioperative morbidity after radical cystectomy in Chinese series is substantial: one reported series documented a complication rate of 76.9%, with 22.2% of patients experiencing two or more concurrent complications, and 90-day perioperative mortality of 2.2–2.7% 5. Urinary diversion selection patterns also reflect inequity: a multicenter Asian RARC consortium study (2007–2020) found that orthotopic neobladder — which offers superior quality of life and is perioperatively safe, with no significant survival difference versus ileal conduit after multivariable adjustment — was selected in only 39.7% of cases 25. A Chinese cross-sectional survey confirmed that sexual satisfaction is universally poor in patients with ileal conduit, and that quality of life is strongly associated with employment, income level, and family social support — predictors that directly disadvantage rural and lower-income populations 27.
4. Bladder-Preservation Pathways: Multidisciplinary Gaps and Radiotherapy Capacity
Trimodality therapy (TMT) — maximal TURBT, concurrent chemoradiation, and intensive surveillance — offers cancer-specific survival rates of 64–71% at 5 years, comparable to radical cystectomy, with the substantial advantage of bladder preservation and improved quality of life for appropriately selected patients 15. However, some reports suggest that many physicians face institutional barriers to implementing TMT, even when presented with a suitable candidate 5.
The barriers are structural and systemic. TMT requires concurrent cisplatin-based chemotherapy (typically 35–40 mg/m² weekly during radiotherapy), image-guided intensity-modulated external-beam radiotherapy with dose escalation to 60–66 Gy, routine multidisciplinary tumour board coordination, and intensive cystoscopic surveillance. While the 2024 Chinese Bladder-Preservation Multidisciplinary Therapy Consensus acknowledges these requirements 20, it does not specify radiotherapy capacity distribution across Chinese provinces, multidisciplinary team availability in lower-tier centres, or mechanisms for patient referral to TMT-capable institutions. These omissions reflect the reality that standardised TMT delivery — described as "yet to be standardised" globally 5 — is even further from routine practice in China outside of major metropolitan academic centres.
Meta-analysis of 87 matched cohort studies (n = 28,218) confirmed no significant difference in overall survival (HR 1.05; 95% CI 0.78–1.40) or cancer-specific survival (HR 1.05; 95% CI 0.69–1.58) between TMT and radical cystectomy, with complete response achieved in 74.4% of TMT-treated patients and grade ≥3 acute toxicity in 11.4% 1. A Chinese multicenter cohort (n = 1,782, propensity-score matched) found a potentially higher intermediate-term mortality with TMT (HR 1.26 at 5 years; 5-year OS 69% TMT vs. 73% RC) 2, which may partly reflect suboptimal patient selection or incomplete chemoradiation protocols rather than an inherent inferiority of the modality. This further underscores that TMT outcomes in China depend critically on the quality of delivery infrastructure.
5. Systemic Health Inequity and Cumulative Impact on Patient Outcomes
The practice gaps described above do not affect all Chinese patients equally. National health system analyses demonstrate that rural residents are significantly more likely to experience catastrophic health expenditure despite lower absolute out-of-pocket costs (AOR 1.30 at the 20% threshold) 10, reflecting that reduced spending represents forgone care rather than genuine financial protection. Urban residents have higher odds of adequate access to care (AOR 2.24 versus rural; P = 0.0018) 11. Wealth-related inequality in cancer-related services is substantially wider in rural areas (relative index of inequality 7.45 vs. 1.64 in urban areas) 10. As bladder cancer disproportionately affects older adults — and China's population aged 65+ is projected to reach 20% by 2027 11 — these rural-urban and socioeconomic disparities will translate into an expanding burden of undertreated and undertriaged bladder cancer.
The table below summarises the key practice gaps, their evidence base, and their clinical consequences.
| Practice Gap | Key Evidence | Clinical Consequence |
|---|---|---|
| BCG shortage forcing maintenance compression or chemotherapy substitution | 3-year RFS 38.0% vs. 60.2% (shortage vs. non-shortage) 12 | Higher recurrence and progression to MIBC |
| Inconsistent immediate post-TURBT intravesical chemotherapy | 35% reduction in 5-year recurrence with single-dose instillation 1 | Preventable early recurrences in low-to-intermediate risk patients |
| Lack of salvage intravesical options for BCG-refractory disease | No established effective salvage intravesical therapy 6 | Premature cystectomy or disease progression in BCG-refractory CIS |
| NAC underutilisation before radical cystectomy | 5–8% absolute survival benefit foregone; pCR rates 9.4% (carboplatin) vs. 36–42% (cisplatin) 6 | Preventable mortality and upstaging at cystectomy |
| Low-volume cystectomy outside tertiary centres | 5-year OS 30.1% (low-volume) vs. 37.7% (high-volume) 15 | 7.6 percentage-point preventable survival loss |
| Neobladder underutilisation (60% ileal conduit) 25 | Poor sexual satisfaction universal in ileal conduit patients 27 | Avoidable quality-of-life loss, particularly in younger patients |
| Limited TMT infrastructure outside major centres | 65% of physicians cannot implement TMT 5 | Patients denied effective bladder-preservation option; unnecessary cystectomy |
| Rural-urban healthcare inequity | AOR 2.24 for adequate care access (urban vs. rural) 11 | Disproportionate recurrence, progression, and mortality in rural/low-income populations |
Conclusion
China's bladder cancer care landscape is shaped by five interconnected structural deficits: BCG supply vulnerability; inequitable access to intravesical chemotherapy and advanced delivery technologies; limited surgical centralisation and NAC utilisation for MIBC; fragmented multidisciplinary infrastructure for TMT; and deep rural-urban and socioeconomic inequity. These are not isolated clinical problems but a compounding system failure that drives measurably higher recurrence, accelerated progression to muscle-invasive disease, preventable perioperative morbidity, unnecessary cystectomy, and avoidable mortality — with the heaviest burden falling on older, rural, and lower-income patients. Addressing these gaps demands coordinated action: stabilising the BCG supply chain, standardising post-TURBT instillation protocols with accountability metrics, centralising cystectomy to high-volume institutions with defined referral pathways, expanding radiotherapy and multidisciplinary infrastructure to enable TMT outside major academic centres, and ensuring equitable reimbursement across all insurance schemes for evidence-based intravesical and systemic agents. The 2025 NMIBC consensus and 2024 bladder-preservation consensus represent important advances in clinical guidance 1720, but the critical question — whether updated recommendations penetrate community hospitals and lower-volume centres — remains unanswered and should be the focus of urgent implementation research.