Bladder Cancer

Treatment options

Making decisions about bladder cancer treatment can be difficult because of all the options and factors that must be considered. Talk openly with your cancer care team and ask questions about the available treatment options so you can determine the best choice for your individual diagnosis.

The most common treatments for bladder cancer include surgery, intravesical therapy, chemotherapy and radiation therapy. You may also receive palliative (supportive) therapy to relieve any symptoms and side effects you may have.

Surgery

Many early-stage bladder cancers can be diagnosed and treated solely with transurethral surgery, also called transurethral resection (TUR) or transurethral resection of a bladder tumor (TURBT). In this procedure, a resectoscope – a thin tube with a lens and a light on one end – is inserted through the urethra into the bladder to remove the tumor. No incisions are necessary, but you will be given either general anesthesia (to put you to sleep) or a regional anesthesia (to numb your lower body). If any cancer remains after the surgery, a second treatment approach may be needed.

When bladder cancer is invasive, more extensive surgery may be needed to remove all or part of the bladder, depending on the size and location of the tumor. The procedure to remove the bladder is called a cystectomy. Removal of only a portion of the bladder is called a partial cystectomy; removal of the entire bladder is called a radical cystectomy. Surrounding lymph nodes and nearby organs, such as the prostate in men and the ovaries, fallopian tubes, uterus and vagina in women, may also be removed. Typically, cystectomy is done through a long incision in the belly, but laparoscopic surgery may be an option. Laparoscopic surgery involves several small incisions through which surgical instruments are inserted to remove the bladder and any affected organs nearby.

When the bladder is removed, a new way to store and eliminate urine is needed. Several surgical options are available, and choosing the best one will depend on your overall health and personal preference. Additional information on bladder removal and reconstruction can be found here.

Intravesical therapy

Intravesical therapy is the administration of medication directly to the bladder through a catheter. The medication targets the urothelial cells that line the bladder wall; these medications are limited in their ability to penetrate the bladder wall, so intravesical therapy is typically only effective for early-stage, noninvasive tumors.

The two main types of medications used in intravesical treatment are immunotherapy and chemotherapy.

The immunotherapy drug, Bacillus Calmette-Guerin (BCG), is a modified tuberculosis bacteria approved for the treatment of early-stage bladder cancer and as treatment to reduce the risk of recurrence in noninvasive bladder cancers, commonly after surgery to remove the tumors. Treatment through intravesical therapy with BCG has been shown to increase the chance of a complete response after surgery. When it is injected into the bladder, it causes inflammation that results in an immune response (see Figure 1). This immune response brings the body’s immune cells directly to the bladder, where they can destroy bladder cancer cells.

Intravesical chemotherapy allows chemotherapy drugs to attack the cancer without affecting other parts of the body, as is the case with standard (systemic) chemotherapy. Intravesical chemotherapy drugs commonly used to treat bladder cancer include mitomycin-C, gemcitabine (Gemzar) and valrubicin (Valstar).

Figure 1

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells or stop their ability to grow.

  • Intravesical (local) chemotherapy involves drugs being delivered into the bladder through a catheter that is inserted through the urethra. Local treatment only destroys superficial tumor cells that come in contact with the chemotherapy solution. It cannot reach tumor cells that have invaded the muscular layer of the bladder wall or tumor cells that have spread to other organs.
  • Systemic chemotherapy travels through the bloodstream to reach cancer cells throughout the body and can be given using an intravenous (IV) tube placed into a vein using a needle or in a pill taken orally.

Radiation therapy

Radiation therapy is usually not used as a primary treatment for bladder cancer, but may be given alone or with chemotherapy to destroy cancer cells that may remain after TURBT, to relieve symptoms or to treat advanced bladder cancer.

Chemoradiation therapy

A combination of chemotherapy and radiation therapy, known as chemoradiation, may be given after the bladder tumor is removed (using TURBT), or instead of surgery. This treatment approach is considered a “bladder-preservation” option because removal of the bladder may not be necessary if no cancer is detected after treatment (see sidebar below).

 

Bladder-Preservation Therapy

Over the last 20 years, national and international clinical trials have been held to test bladder preservation in patients with invasive bladder cancer by combining surgical transurethral resection of the bladder tumor (TURBT) with external beam pelvic radiation concurrently with systemic chemotherapy (chemoradiation).

These trials, conducted by the National Cancer Institute in the United States as well as by organizations in both the United Kingdom and Europe, show this technique is well tolerated and can be an option for some people to avoid the need for bladder removal.

Patients believed to be good candidates for chemoradiation therapy include those whose tumors:

  • appear to be have been completely removed by TURBT
  • have invaded no deeper than the muscle wall
  • have not obstructed a ureter

Prior to choosing your treatment plan for invasive bladder cancer talk to your cancer treatment team, ideally in a multidisciplinary bladder cancer specialty clinic including a radiation oncologist, a medical oncologist and a urologist about whether bladder preserving therapy is an option. Additional facts about this procedure include:

  • It is well tolerated—even in the elderly
  • If bladder removal is necessary for recurrence the surgical complication rates for cystectomy are similar to those without prior chemoradiation
  • High survival rates from cancer are stable from 5 to 15 years
  • The retained bladder functions well

If you choose this type of treatment, you will have a strict follow-up schedule to be monitored for signs of recurrence. It is important so that if your cancer does return, you can move forward with the best treatment for recurrent disease. Evidenced-based medicine now shows that TURBT plus chemoradiation can be a patient-friendly approach for the well-selected patient.

Treatment options by stage

Stage Commonly recommended treatment options
0
  • Transurethral surgery, sometimes followed by intravesical therapy to help prevent recurrence
I
  • Cystectomy, if several tumors are in the bladder
  • Radiation therapy (often in combination with chemotherapy), for people who are unable to have surgery
  • Transurethral surgery, followed by intravesical therapy to help prevent recurrence
II
  • Chemotherapy, either before or after surgery, to reduce the risk of recurrence
  • Transurethral surgery followed by radiation therapy and chemotherapy, for people who are unable to have surgery
  • Transurethral surgery, usually to determine the extent of the cancer, typically followed by partial or radical cystectomy
III
  • Chemotherapy, either before or after surgery, to reduce the risk of recurrence
  • Transurethral surgery followed by radiation therapy and chemotherapy, for people who are unable to have surgery
  • Transurethral surgery, usually to determine the extent of the cancer, typically followed by radical cystectomy
IV
  • Chemotherapy
  • Cystectomy, if chemotherapy or radiation therapy shrinks the tumor enough
  • Immunotherapy
  • Radiation therapy, for patients unable to tolerate chemotherapy
IV (metastatic)
  • Chemotherapy, sometimes in combination with radical cystectomy or radiation therapy
  • Immunotherapy
  • Palliative chemotherapy, radiation therapy or a combination to lengthen survival, control symptoms and improve quality of life
  • Palliative surgery, such as urinary diversion without cystectomy to prevent or relieve a urine blockage and reduce pain and other symptoms

Clinical trials

Clinical trials are the controlled studies of investigational drugs or other types of treatment. In some cases, patients may want to participate in a clinical trial to gain access to certain treatments before they are officially approved. New drugs for advanced bladder cancer are showing promise in early clinical trials, so talk to your doctor about any trials that may be appropriate for your diagnosis. Knowing all of your treatment options, including trials, will help you make more informed decisions about your cancer care.

Treating recurrent bladder cancer

If bladder cancer returns after treatment, it is called recurrent cancer. Recurrence can happen weeks, months or even years after treatment stops, and the cancer may come back in the same area of the body as the primary cancer (local recurrence), or in a different area of the body (distant recurrence). While doctors cannot be certain about which patients will have cancer recurrence, they can often make predictions based on the recurrence patterns of some cancers. For example, when noninvasive bladder cancer recurs, it is most commonly local recurrence, in either the same site as the original tumor or elsewhere in the bladder. Treatment options for recurrent cancer depend on the location and extent of the tumor, treatment history and overall health.

Additional Resources

 

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