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Cancer Medicine :: Bladder Cancer Treatment

Bladder Cancer

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options.              

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

Descriptions of the most common treatment options for bladder cancer are listed below. Treatment options and recommendations depend on several factors, including the type, stage, and grade of bladder cancer, possible side effects, and the patient’s preferences and overall health.

Early-stage bladder cancer can often be treated locally (treatments that just involve the bladder) without removing the whole bladder. Later-stage bladder cancer is often treated with systemic chemotherapy (see below). In later-stage bladder cancer, it may or may not be necessary to remove the bladder during surgery. Radiation therapy may also be used instead of removing the bladder.

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. There are different types of surgery for bladder cancer treatment, depending on the stage of the disease. A urologist or urologic oncologist is a doctor who specializes in treating bladder cancer using surgery. Surgical options to treat bladder cancer include the following:

TURBT with fulguration. This procedure is often used for early-stage cancer. It is a treatment for non-muscle-invasive cancer and is used to find out the stage, which helps doctors plan treatment. It may also be used to rule out muscle-invasive cancer before using intravesical chemotherapy (see below). During TURBT, the surgeon inserts a cystoscope through the urethra into the bladder and removes the cancer using a tool with a small wire loop or using a laser or fulguration (high-energy electricity). This procedure is done with an anesthetic so it is not painful.

Cystectomy. This procedure is often used for deeply invasive cancer or a noninvasive cancer that has recurred. A radical cystectomy is the removal of the whole bladder and possibly nearby tissue and organs. For men, the prostate and urethra also may be removed. For women, the uterus, fallopian tubes, ovaries, and part of the vagina also may be removed. Lymph nodes in the pelvis are also removed for both men and women; this is called a pelvic lymph node dissection. Recent research suggests that doing a thorough pelvic lymph node dissection may be beneficial. In some situations, only part of the bladder may be removed, called a partial or segmental cystectomy. Research shows that chemotherapy before or after a radical cystectomy may increase survival for men with muscle-invasive bladder cancer.

In a laparoscopic or robotic cystectomy, the surgeon makes several small incisions instead of the one larger incision used in traditional surgery. The surgeon uses telescoping equipment with or without robotic assistance to remove the bladder. The surgeon must make an incision to remove the bladder and surrounding tissue. This surgery may take longer, but it is less painful afterward and patients may recover more quickly. Several studies are in progress to determine whether laparoscopic or robotic cystectomy is as safe as the standard surgery and whether it is able to cure bladder cancer as successfully as standard surgery.

Urinary diversion. If the bladder is removed, the doctor will make a new way to pass urine out of the body by using a section of the small intestine to divert urine to a stoma or ostomy (an opening) to the outside of the body. The patient wears a bag attached to the stoma to collect and drain urine.

Increasingly, surgeons can use part of the small or large intestine to make a urinary reservoir, which is a storage pouch that sits inside the body. For some patients, the surgeon is able to connect the pouch to the urethra, creating what is called a neobladder, so the patient can pass urine out of the body normally. For other patients, the pouch is connected to the skin on the abdomen by a small stoma creating a type of continent urinary reservoir, meaning that the urine will stay in the reservoir until the patient drains the pouch and no urinary pad is needed. The pouch is drained by inserting a catheter (a thin tube) through the small stoma and then removing the catheter and covering the stoma with a bandage.

The side effects of bladder cancer surgery depend on the procedure. Patients should talk with their doctor in detail to understand exactly what side effects may occur, including urinary and sexual side effects, and how they can be managed. In general, the side effects may include:

Mild bleeding and discomfort after surgery.

Infections or urine leaks after cystectomy or a urinary diversion, and if a neobladder is created, a patient may sometimes be unable to urinate or completely empty the bladder.

Men may be unable to have an erection (called impotence) after cystectomy. Sometimes, a nerve-sparing cystectomy can be performed. When this is done successfully, men may be able to have a normal erection.

Damage to the nerves in the pelvis and loss of sexual feeling and orgasm for both men and women. Often, these problems can be fixed. Patients should talk with their doctor about any side effects they are experiencing. 

Bladder preservation or substitution. Living without the bladder can affect a patient’s quality of life. Finding ways to keep all, or part, of the bladder is important whenever possible, especially if removing the bladder will not lengthen a person’s life.

For some patients, certain treatment plans involving chemotherapy and radiation therapy (see below) may be used instead of removing the bladder.

As explained above, sometimes surgeons can use part of the intestine to create a substitute for the bladder by making a neobladder or continent urinary reservoir. With these procedures, the patient does not need a urinary bag and can have a better quality of life. However, the patient may need to insert a catheter if urine does not empty through the neobladder. Also, patients with a neobladder will no longer have the urge to urinate and will need to learn to urinate on a consistent schedule.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. A chemotherapy regimen typically consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

For bladder cancer, doctors may decide to use one of two types of chemotherapy: intravesical (local) or systemic (whole body) treatment. In general, patients with non-muscle-invasive bladder cancer are more likely to be treated with intravesical chemotherapy after TURBT to reduce the risk of recurrence in the bladder. Patients with muscle-invasive cancer located only in the bladder often receive chemotherapy before (neoadjuvant therapy) or after (adjuvant therapy) cystectomy to reduce the risk of the cancer spreading to other parts of the body. Patients should talk with their doctor about chemotherapy before surgery.

The types of chemotherapy most often used for bladder cancer are described in more detail below:

Intravesical therapy. Intravesical chemotherapy is usually given by a urologist. In this type of therapy, drugs are placed into the bladder through a catheter inserted into the bladder through the urethra. Local treatment kills only non-muscle-invasive tumor cells. It cannot reach tumor cells in the bladder wall or tumor cells that have spread to other organs. The most common drug that is given as intravesical treatment is an immunotherapy drug called BCG (see Immunotherapy, below). However, other types of drugs are also used. The most common is mitomycin C (Mitozytrex, Mutamycin). The drugs thiotepa (multiple brand names), doxorubicin (Adriamycin), and gemcitabine (Gemzar) have also been used.

Systemic chemotherapy. Systemic chemotherapy is usually given by a medical oncologist, a doctor who specializes in treating cancer with medication. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. It is generally given intravenously (IV; given by injection in a vein).

For bladder cancer, there are several drugs available, and many of the systemic chemotherapy regimens continue to be tested in clinical trials to help determine which drugs, or which drug combinations, work best to treat bladder cancer. Usually a combination of drugs works better than one drug alone. Researchers are also studying when it is best to use chemotherapy, either before or after surgery.

A combination of drugs, called MVAC, has been used as the standard treatment for bladder cancer for many years. MVAC has helped delay bladder cancer recurrence, and extend life and cure patients, but it has severe side effects. MVAC uses four drugs: methotrexate (multiple brand names), vinblastine (Velban, Velsar), doxorubicin, and cisplatin (Platinol). The combination of gemcitabine plus cisplatin is also used and works similarly to the MVAC combination but with somewhat fewer side effects. Other drugs are being studied in clinical trials to determine if there is a combination of drugs that will work better and have fewer side effects.

Side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

Chemotherapy for localized muscle-invasive bladder cancer. Researchers are studying new combinations of chemotherapy that are more effective in managing bladder cancer. Treatments may include:

Combinations of different drugs

Currently used drugs tested in different doses

Drugs or drug combinations given before or after surgery

Drugs or drug combinations given with radiation therapy. If radiation therapy is combined with chemotherapy, it may make chemotherapy more effective in an effect called radiosensitizing.

Recently, an important clinical trial has shown that the use of intravenous chemotherapy (the MVAC regimen, mentioned above) before radical cystectomy helps patients with invasive bladder cancer live longer. Based on this research, this approach is considered a standard treatment. This type of initial chemotherapy, called neoadjuvant chemotherapy, may shrink the tumor in the bladder and may also kill small areas of cancer that have spread beyond the bladder. It is important to note that chemotherapy with one drug does not seem to help patients with locally advanced bladder cancer live longer, and some patients may not be healthy enough to receive chemotherapy. Therefore, it is recommended that all patients with muscle-invasive bladder cancer talk with their medical oncologist about their treatment options, including the risks and benefits of chemotherapy.  

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Immunotherapy

Immunotherapy (also called biologic therapy) is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to bolster, target, or restore immune system function. The standard immunotherapy drug for bladder cancer is a weakened bacterium called bacillus Calmette-Guerin (BCG), which is similar to a form of the germ that causes tuberculosis. BCG is placed directly into the bladder through a catheter (called intravesical therapy; see below). BCG attaches to the inside lining of the bladder and attracts the patient's immune cells to the bladder to fight the tumor.

BCG is used mostly for patients with non-muscle-invasive, high-grade bladder cancer to reduce the risk of the cancer recurring or progressing. A first course of BCG is given weekly for six weeks. Six weeks later, the doctor performs a cystoscopy and sometimes a bladder biopsy to determine if the BCG has eliminated all of the cancer. Patients with no remaining evidence of cancer undergo maintenance therapy, which may be given as three one-week treatment cycles every six months for three years. Before BCG treatment, patients will need to have another TURBT to make sure that the cancer has not spread to the muscle. BCG treatment may help patients avoid a cystectomy. Patients receiving BCG require long-term monitoring with cystoscopy and urine cytology to be sure the cancer does not return. 

BCG can cause flu-like symptoms, chills, mild fever, fatigue, a burning sensation in the bladder, and bleeding from the bladder. Interferon (Roferon-A, Intron A, Alferon) is another immunotherapy drug that can be given as intravesical therapy. It is sometimes combined with BCG if BCG alone does not help treat the cancer. 

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation therapy is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

Radiation therapy is usually not used as a treatment alone for bladder cancer but is given in combination with chemotherapy. However, some patients who cannot receive chemotherapy might receive radiation therapy alone. The combination of radiation therapy and chemotherapy may be used to treat cancer that is located only in the bladder for the following reasons:

To destroy any remaining tumor after TURBT while sparing the bladder

To relieve symptoms caused by a tumor, such as pain, bleeding, or blockage

To treat a metastasis located in one area, such as the brain or bone

Side effects from radiation therapy may include fatigue, mild skin reactions, and loose bowel movements. For bladder cancer, side effects most commonly occur in the pelvic or abdominal area and may include bladder irritation with the need to pass urine frequently during the treatment period, and bleeding from the bladder or rectum. Most side effects go away soon after treatment is finished.

Palliative/supportive care

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible.    

Recurrent bladder cancer

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED. 

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. 

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, chemotherapy, and radiation therapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Metastatic bladder cancer

If the cancer has spread to another location in the body other than the pelvic lymph nodes, it is called metastatic cancer.

Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials studying new treatments.

Your health care team may recommend a combination of treatments to help manage the cancer. There are no methods to permanently cure metastatic bladder cancer for most people. The goals of treatment are to slow the spread of cancer, shrink the tumor (called temporary remission), relieve symptoms, and extend life as long as possible. With advances in treatment, most patients with metastatic bladder cancer can expect to live many months or even years longer than they could just a few years ago.

As explained above, the MVAC and gemcitabine-cisplatin regimens are the current standard treatments for patients who are healthy enough to receive such therapy. There are other drugs and combinations that can be used for patients who for medical reasons are unable to receive gemcitabine-cisplatin or MVAC. Changes to these regimens or the use of new treatment regimens that help patients live longer and improve their quality of life are being studied in clinical trials. Since there are relatively few treatment options for metastatic bladder cancer, clinical trials are often the best option for treatment. Supportive care will also be important to help relieve symptoms and side effects.

For many patients, a diagnosis of metastatic cancer can be very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

If treatment fails

Recovery from bladder cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Palliative care given toward the end of a person’s life is called hospice care. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.

Coping with Side Effects

Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments use in the past. Doctors also have many ways to provide relief to patients when such side effects occur.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for bladder cancer are described in detail within the Treatment section. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with bladder cancer.

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

After Treatment

After treatment for bladder cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. 

For bladder cancer, follow-up care typically includes a general physical examination, cystoscopy, urine cytology, x-rays, and routine blood tests to make sure the bladder is working well and to check for any signs that the cancer has come back. Tell your doctor about any new symptoms, such as pain during urination, blood in the urine, frequent urination, or an immediate need to urinate. These symptoms may be signs that the cancer has come back or signs of another medical condition.

For patients with a urinary diversion, follow-up care may include checking for infection with urine tests, checking and fixing problems with controlling urination, checking for recurrent cancer in the upper urinary tract, and checking for changes in kidney function with blood tests and x-rays.

People recovering from bladder cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. 

Latest Research

Doctors are working to learn more about bladder cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. For bladder cancer, ongoing research is indicating that a PET scan may help find bladder cancer that has spread better than a CT scan or MRI alone.

Laparoscopic cystectomy. As outlined in Treatment under Surgery, several studies are underway to find out whether laparoscopic bladder removal is as safe as the standard surgery and whether the cure rates are the same.

Photodynamic therapy (PDT). PDT may be useful to treat early stages of bladder cancer. During photodynamic therapy, a patient receives an injection of a nontoxic chemical that collects in the tumor for a few days. Then, the doctor focuses a special laser on the cancer, which changes the chemical in the tumor into a new chemical that can kill the tumor with very little harm to normal cells.

Molecular testing. Tests to identify changes to genes or proteins that could be a sign of bladder cancer may help predict a bladder cancer recurrence or predict which patients may need more aggressive treatment. DNA changes may also help predict prognosis for people with bladder cancer.

Targeted therapy. Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to normal cells. Research is underway to determine how targeted therapy may be used to treat bladder cancer. For instance, a clinical trial is looking at combining targeted therapy with radiation therapy to help preserve bladder function.

New drugs and drug combinations. As described in the Treatment section, researchers are studying new drugs and new combinations of chemotherapy.

Supportive care. Clinical trials are underway to find a better way of reducing symptoms and side effects of current bladder cancer treatments in order to improve patients’ comfort and quality of life.

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