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

Your doctor considers many factors, including the tumor’s stage, grade and biomarker status; whether the cancer is non-muscle invasive or muscle-invasive; potential side effects; your general health; and your preferences concerning quality of life. These treatment options may be used alone or in combination.

Surgery may be recommended. Different procedures include the following:

  • Transurethral bladder tumor resection (TURBT). A surgeon inserts a cystoscope through the urethra into the bladder and removes the tumor using an instrument with a small wire loop, a laser or high-energy electricity.
  • Cystectomy. A radical cystectomy removes the entire bladder and may also include nearby tissues or organs. Lymph nodes in the pelvis are also removed. In addition, men may have their prostate and urethra removed, and women may have their uterus, fallopian tubes, ovaries and part of the vagina removed. A partial (segmental) cystectomy may be performed to remove only a portion of the bladder, preserving the ability to urinate normally.
  • Urinary diversion. If your bladder is removed, a continent urinary diversion allows you to have some control of the flow of urine out of your body. There are two common types, and you and your treatment team will determine which diversion will work best for you.

One type includes the surgeon using a section of your intestine that is attached to your ureters (tubes through which urine normally flows from the kidneys to the bladder) to create an internal pouch to store urine. Urine is then diverted to a stoma (a surgically-made hole) in your abdomen.

Another option involves the surgeon creating a neobladder, also referred to as a substitute bladder, using a portion of your intestine. One end is attached to the ureters and the other end to the urethra (tube through which urine exits the body). Urine would leave your body in the regular way. An external collection bag is not needed. Over time, you may be able to regain some control of your urination. 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.

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.

Immunotherapy

Immunotherapy may include immune checkpoint inhibitors, which prevent certain receptors and proteins from telling the immune system to slow down when they connect with cancer cells.

Another option involves injecting modified tuberculosis bacteria directly into the bladder through a catheter (intravesical therapy), which stimulates an immune response that brings the body’s immune cells directly to the bladder to destroy cancer cells.

Also used are monoclonal antibodies (mAbs), which are laboratory-made antibodies designed to target specific tumor antigens. They work in different ways and can carry cancer drugs, radiation particles or laboratory-made cytokines (proteins that enable cells to send messages to each other) directly to cancer cells. When a mAb (pronounced mab) is combined with a toxin, such as a chemotherapy drug, it travels through the system until it reaches the targeted cancer cell, releasing the toxin and causing cell death.

Targeted Therapy

Targeted therapy may treat some bladder cancers with the fibroblast growth factor receptor (FGFR2 or FGFR3) gene mutation. These mutations can be blocked by special oral targeted therapy drugs, which are specific kinase inhibitors. There are also data suggesting that tumors with mutated FGFR3 are less likely to be recognized by the immune system.

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.

Common Drug Therapies

Commonly Used Medications 

Chemotherapy
cisplatin
doxorubicin (Adriamycin)
methotrexate
mitomycin (Jelmyto, Mitozytrex, Mutamycin)
thiotepa (Tepadina)
valrubicin (Valstar)
Immunotherapy
   Cytokine
interferon (Roferon-A, Intron A, Alferon)
   Immune Checkpoint Inhibitors
avelumab (Bavencio)
durvalumab (Imfinzi)
nivolumab (Opdivo)
pembrolizumab (Keytruda)
sacituzumab govitecan-hziy (Trodelvy)
   Modified Bacteria
bacillus Calmette-Guérin (BCG)
   Monoclonal Antibody
enfortumab vedotin-ejfv (Padcev)
Targeted Therapy
   Kinase Inhibitor
erdafitinib (Balversa)
Some Possible Combinations
carboplatin (Paraplatin) and gemcitabine (Gemzar)
cisplatin and gemcitabine (Gemzar)
Dose dense (DD)-MVAC (methotrexate, vinblastine [Velban, Velsar], doxorubicin [Adriamycin] and cisplatin)
MVAC - methotrexate, vinblastine (Velban, Velsar), doxorubicin (Adriamycin) and cisplatin

As of 4/14/21

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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