There are four primary categories of bladder cancer treatment: chemotherapy, intravesical therapy, radiation therapy (radiotherapy), and surgery. Sometimes these are applied as a sole therapy and sometimes combinations of therapies will be used. The proper course of bladder cancer treatment is determined only after careful characterization of bladder cancer and consultation between the patient and his or her physician.
When considering bladder cancer treatment, a variety of factors come into play, including the nature of the cancer, the age and health of the patient, other conditions that may exist, and patient preference of bladder cancer treatment following patient education. Often other specialists will be called in to consult on the treatment. This insures that the treatment that is eventually determined is tailored to the patient and his or her cancer.
In general, superficial tumors of the bladder lining are treated with surgery and/or medical therapy. Invasive tumors that have penetrated one or more of the bladder’s walls require surgery that removes a portion or all of the bladder. Medical therapy and/or radiation treatments may be applied. The bladder is usually not removed when a cancer metastasizes. Chemotherapy is the standard treatment for metastatic bladder cancer.
Chemotherapy - Chemotherapy drugs take advantage of cancer cells’ propensity to grow faster than other cells. Since they are growing, they greedily absorb nutrients. During bladder cancer treatment, cancer cells also absorb anti-cancer drugs at a much higher rate than normal cells. This is how chemotherapeutic agents destroy cancer while leaving normal cells unharmed. Chemotherapeutic agents are administered intravenously, sometimes as sole agents, sometimes in combination, and sometimes in tandem with the administration of one therapy followed by another in a few days or weeks. Because the agents are administered intravenously, they reach all parts of the body and can have strong side-effects. Chemotherapy is usually indicated in patients with Stage IV bladder cancers and frequently as follow-up therapeutic treatment in Stage III surgical patients as a means to prevent recurrence.
The most commonly used agents are methotrexate, vinblastine, doxorubicin, cyclophosphamide, paclitaxel, carboplatin, cisplatin, ifosfamide and gemcitabine. These drugs are often used in combinations. The combination of gemcitabine and cisplatin has been shown to have fewer side effects than the MVAC regimen (methotrexate, vinblastine, doxorubicin and cisplatin) and is perhaps more frequently used. A paclitaxel-carboplatin is also frequently used. All these agents produce some degree of side effects in the course of bladder cancer treatment.
Selection of a bladder cancer treatment regimen depends on the nature of the cancer and the health of the patient, i.e. whether he or she has other diseases or conditions. The most effective regimen is given priority. Then side effects are considered. Side effects include tiredness, nausea and vomiting, diarrhea or constipation, hair loss, susceptibility to infections, and oral responses such as mouth ulcers, sore mouth and changes in sense of taste. Many of these side effects can be moderated or eliminated by other drugs.
Intravesicle therapy - Intravesicle therapy is the introduction of chemotherapeutic agents or biological agents (immunotherapy) in a fluid directly into the bladder through a catheter (flexible tube) threaded through the ureter. The process reduces or eliminates many of the side effects seen with intravenous therapy. Biological therapy or immunotherapy is the intravesicle administration of a special non-infectious strain of the Bacillus Calmette-Guerin bacteria. It is not known in great detail how the virus works against cancer. It does not appear to attack cancer cells directly but rather produces a response from the immune system that targets and destroys cancer cells specifically.
Radiation - Radiation, like chemotherapy, takes advantage of cancer’s cells propensity to grow rapidly. The cancer cells’ constantly changing status makes them exceedingly susceptible to radiation treatment which destroys their DNA but leaves normal cells relatively unharmed. New imaging technologies allow tumors to be identified with improved clarity and computer-guided, focused radiation delivery systems minimize radiation exposure to adjacent organs and tissues.
Surgical Options - As with the other therapies, the nature of the bladder cancer surgery depends on the nature of the cancer. People with Stage 0 or Stage I disease are most often treated with transurethral resection of the bladder (TURB). The procedure is performed under general or spinal anesthesia. A thin tube is inserted through the urethra. Miniaturized fiber optics and miniaturized surgical instruments are threaded through the tube to remove cancerous tissue.
Partial cystectomy - Removal of only a portion of the bladder is a viable option when a tumor is invasive but all evidence indicates that it is a solitary tumor limited to a defined region of the bladder. The procedure reduces the size of the bladder but preserves a significant portion. Partial cystectomies may be accompanied by radiation and chemotherapy treatment. It is possible to increase bladder volume by incorporating tissue taken from another location, usually the intestine. Since the tissue is derived from the patient, there is seldom concern about tissue rejection.
The National Cancer Institute reports that an increasing number of urologists are supporting the concept of bladder preservation. Patient undergoing this conservative approach have done well and are not excluded from undergoing complete removal of the bladder (radical cystectomy) should the cancer recur at a later date.
Radical cystectomy - This procedure involves complete removal of the bladder. An incision is made in the abdomen and the bladder and adjacent organs are carefully examined to determine the status of the cancer and see if it may have spread to adjacent structures and organs. The bladder is removed along with any other organs that may be affected.
Reconstructive procedures - Several options are available to the patient who has lost a bladder. In a procedure called urostomy, a segment of intestine is removed and reattached to the ureters. This leads urine from the kidneys an opening (stoma) near the belly button. A light, leak proof bag is attached to the stoma to collect urine. The bag can be emptied as needed.
A segment of intestine can also be formed into a small pouch or a larger "neobladder." The pouch or bladder is placed in the cavity left by the bladder and stores urine. A conduit, again made from intestine, leads to a stoma in the abdomen but in this instance a valve allows the pouch to be drained whenever he or she wishes. No bags are involved. The neobladder may be attached to the urethra to allow urine to be drained normally. The application of these procedures is dependant upon a number of factors. They are not available to all patients but these bladder cancer treatments can be successfully implemented in many.
Treatment option overview
There are different types of treatment for patients with bladder cancer.
Different types of treatment are available for patients with bladder cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.
Clinical trials are taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.
Four types of standard treatment are used:
Surgery
One of the following types of surgery may be done:
Transurethral resection (TUR) with fulguration: Surgery in which a cystoscope (a thin lighted tube) is inserted into the bladder through the urethra. A tool with a small wire loop on the end is then used to remove the cancer or to burn the tumor away with high-energy electricity. This is known as fulguration.
Radical cystectomy: Surgery to remove the bladder and any lymph nodes and nearby organs that contain cancer. This surgery may be done when the bladder cancer invades the muscle wall, or when superficial cancer involves a large part of the bladder. In men, the nearby organs that are removed are the prostate and the seminal vesicles. In women, the uterus, the ovaries, and part of the vagina are removed. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to reduce urinary symptoms caused by the cancer. When the bladder must be removed, the surgeon creates another way for urine to leave the body.
Segmental cystectomy: Surgery to remove part of the bladder. This surgery may be done for patients who have a low-grade tumor that has invaded the wall of the bladder but is limited to one area of the bladder. Because only a part of the bladder is removed, patients are able to urinate normally after recovering from this surgery.
Urinary diversion: Surgery to make a new way for the body to store and pass urine.
Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy after surgery to kill any cancer cells that are left. Treatment given after surgery, to increase the chances of a cure, is called adjuvant therapy.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Bladder cancer may be treated with intravesical (into the bladder through a tube inserted into the urethra) chemotherapy. The way the chemotherapy is given depends on the type and stage of the cancer being treated.
Biologic therapy
Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.
New types of treatment are being tested in clinical trials. These include the following:
Chemoprevention
Chemoprevention is the use of drugs, vitamins, or other substances to reduce the risk of developing cancer or to reduce the risk that cancer will recur (come back).
Photodynamic therapy
Photodynamic therapy (PDT) is a cancer treatment that uses a drug and a certain type of laser light to kill cancer cells. A drug that is not active until it is exposed to light is injected into a vein. The drug collects more in cancer cells than in normal cells. Fiberoptic tubes are then used to carry the laser light to the cancer cells, where the drug becomes active and kills the cells. Photodynamic therapy causes little damage to healthy tissue.
