Bladder cancer poses a wide spectrum of risk to the patient. Well-differentiated, papillary tumors rarely present a threat of death or loss of the bladder. High-grade cancers commonly are lethal, and treatment may greatly alter urinary and sexual function. The physician and patient often face difficult decisions about under- and overtreatment. The initiation of therapy at every stage depends heavily on clinical judgment, because this cancer typically occurs in an older population with significant comorbidities. Even experienced clinicians often find it difficult to separate patients who are appropriate candidates for cystectomy from those in whom it may be unnecessary at one extreme or futile at the other. The integration of effective and less toxic systemic chemotherapy as well as radiation therapy remains a challenge. Substantial progress in the delivery of bladder cancer care is clearly evident in the last two decades, but fundamental uncertainties in management decisions persist.