How Bladder Cancer Is Treated

It's a Complex Process, So Let's Break It Down

Goal of Intravesical Chemotherapy is to Kill Residual Cancer Cells
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A diagnosis of bladder cancer can generate a whole host of emotions ranging from disbelief and anger to sadness and fear. These are all normal reactions, and it's expected that you take some time to think through and grieve this new diagnosis.

That being said, as you process your diagnosis, moving forward with treatment is crucial to optimizing your health and recovery.

While a person's precise bladder cancer treatment plan depends on a number of factors—especially the stage of cancer (how far it has spread) and the grade of cancer (how abnormal the cancer cells look)—one of the easiest ways to think about treatment is to break it down into two paths, depending on your individual diagnosis:

  • treatment of non-muscle invasive bladder cancer
  • treatment of muscle invasive bladder cancer

Treatment of Non-Muscle Invasive Bladder Cancer

According to the American Urological Association, about 75 percent of new bladder cancer cases diagnosed in 2015 were non-muscle invasive bladder cancers. Non-muscle invasive means that the tumor is contained within the bladder and has not penetrated the thick muscular layer of the bladder.

Surgery

The first step in treating non-muscle invasive bladder cancer is a type of surgery called TURBT (transurethral resection bladder tumor), which removes the tumor from the bladder. During a TURBT, a urologist places a rigid, thin instrument with a light and camera on it (called a resectoscope) through a person's urethra into his or her bladder. The resectoscope contains a wire loop that allows the doctor to remove the tumor.

This procedure is usually done in an operating room, and sometimes a second TURBT is required weeks after the first TURBT, to ensure that none of the tumor was missed.

The good news is that most people can go home the same day or the next day after a TURBT. Also, side effects from a TURBT like bleeding or discomfort when urinating are typically short-lived and mild.

Intravesical Chemotherapy

Even though the survival rates are favorable in people with non-muscle invasive bladder cancer, two major concerns doctors have (even after the tumor is removed) are:

  • the cancer coming back—this is called a recurrence and/or
  • the cancer spreading into the muscle or further into the body—this is called a progression

This is why most patients undergo additional therapy after the tumor removal with an intervention called intravesical chemotherapy. With this type of therapy, medication is administered directly into the bladder through a catheter. The purpose of the chemotherapy is to destroy any left over, non-visible cancer cells in the bladder.

Depending on a person's risk of bladder cancer recurrence (which a doctor assesses as low, intermediate, or high), he or she will typically receive either a single dose (at the time of the initial TURBT) or multiple doses over a six-week period of intravesical chemotherapy. Mitomycin is often the chemotherapy of choice administered, and it may cause some burning in the bladder, as well as frequent and/or painful urination.

Intravesical Immunotherapy

Sometimes, instead of intravesical chemotherapy, a person will receive an intravesical immunotherapy called Bacillus Calmette-Guerin (BCG). This type of therapy triggers a person's immune system to kill cancer cells.

It's interesting to note that Bacillus Calmette-Guerin (BCG) was developed initially as a vaccine for tuberculosis, but in the 1970s and 1980s, was found to kill bladder cancer cells.

While very effective, intravesical BCG can cause side effects for up to two days like:

  • fever, chills, body aches
  • fatigue
  • urinating a lot
  • blood in the urine
  • pain when urinating
  • burning within the bladder

Rarely, BCG can spread to the body, causing a whole-body infection, which may be signaled by a fever that occurs for more than two days or a fever that does not improve with medicine. A whole-body infection is a serious medical emergency, requiring immediate medical attention.

Checking for Cancer Recurrence

About three months after treatment with intravesical therapy, and at specific intervals after that, a doctor will perform a cystoscopy to ensure there is no bladder cancer recurrence.

For intermediate to high-risk patients, urine cytology (to look for cancer cells) and imaging of the upper urinary tract (for example, a CT scan) will also often be done periodically, as a further means of monitoring.

If a suspicious area of the bladder is seen, it will be biopsied and removed with TURBT. If cancer has indeed recurred, a person will generally undergo more intravesical therapy or have their bladder removed with a surgery called a cystectomy.

If there is no evidence of recurrence, a person may undergo maintenance therapy with BCG, in order to further prevent any cancer recurrence. The duration of maintenance therapy (for example, one versus three years) depends on a person's risk, which is assessed by his or her cancer team.

Treatment of Muscle-Invasive Bladder Cancer

Radical Cystectomy

Standard treatment of muscle-invasive bladder cancer is a surgery called radical cystectomy, which entails removing the bladder and surrounding organs (prostate and seminal vesicles in men and uterus, cervix, fallopian tubes, ovaries, and the upper part of the vagina in women).

Sometimes radical cystectomy is also recommended for bladder cancer that has not invaded the muscle layer but has other worrisome, aggressive features. Radical cystectomy is also generally recommended in people who have persistent or recurrent non-muscle invasive bladder cancer after treatment with intravesical immunotherapy.

Chemotherapy Prior to Surgery

If a person is healthy enough, he or she will also receive chemotherapy prior to surgery to improve his or her chances of surviving. The purpose of chemotherapy is to kill cancer cells that are in the body but cannot be seen yet.

Two common chemotherapy regimens used prior to surgery for urothelial bladder cancers are:

  • MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin)
  • GC (cisplatin and gemcitabine)

Your oncologist or cancer doctor will administer these chemotherapies in cycles, meaning that after each treatment, you will rest and be monitored for any adverse side effects. Examples of side effects that may be seen with the above regimens include:

Each cycle lasts for a few weeks, and generally, three cycles are recommended prior to bladder surgery.

A New Bladder or Urinary Diversion is Reconstructed

After the bladder is removed, a surgeon must devise a new place for urine to be stored. There are a few options a surgeon can consider:

  • A new bladder can be created from part of a person's intestines (called a neobladder) that is connected to a person's urethra, so they can urinate as before.
  • A pouch can be created inside the body using tissue from the stomach or intestines. One end is connected to the ureters and the other to an opening in the skin on the abdominal wall (called a stoma). A catheter can then be used to empty the urine through the stoma during the day, but the pouch ultimately stores the urine (like a bladder).
  • Instead of a pouch, a piece of intestines is connected to the ureters. With this type of surgery, urine flows from the kidneys to the ureters through the piece of intestines into the stoma and finally drips into a small collection bag located outside the body.

Potential Risks of Surgery

Radical cystectomy and creating a new bladder or pouch is a complex surgery. In other words, it is a big deal, so it's important you understand all the risks and benefits involved—the good and the bad, so to speak.

With that, the likelihood of surgical complications depends on a number of factors like the surgeon's experience, the patient's age, and whether the patient has any underlying medical problems. Still, examples of potential surgical complications include:

Another issue to address with your surgeon is the potential for sexual side effects like erectile dysfunction or sexual arousal, and how you can cope with this if it occurs.

Bladder Preservation

Despite radical cystectomy being the standard treatment for muscle-invasive bladder cancer,  sometimes, a person with invasive bladder cancer may not have their entire bladder removed. They may undergo partial removal of their bladder or a more extensive TURBT. Like any form of treatment, in these unique cases, the risks and benefits need to be carefully analyzed.

Radiation therapy, which is delivered by a radiation oncologist, is usually combined with chemotherapy and TURBT in bladder-preserving protocols, as it is not considered an adequate sole form of therapy.  Radiation kills cancer cells, and treatment sessions typically last five days a week for several weeks.

Metastatic Bladder Cancer

For bladder cancer that has spread to other parts of the body like the lymph nodes or other organs (lungs, liver, and/or bones), chemotherapy may be an option to slow the growth of the cancer. Research into immunotherapy for advanced bladder cancer is also being currently investigated.

Sometimes, too, radiation is given or even surgery is performed like TURBT or cystectomy on a person with metastatic bladder cancer. It's important to understand, though, that these therapies are done as a means of palliative care—a way of easing bothersome symptoms related to the cancer.

This all being said, in the case of metastatic bladder cancer, it's important to consistently address your wishes about whether various cancer treatments are impairing more than improving your quality of life. In this instance, know that it is OK to relay your thoughts to your family and oncologist. In other words, a shorter duration of time may be more fulfilling than a longer period of uncomfortable treatments—this, of course, is an extremely personal and unique decision.

A Word From Verywell

There is no doubting that being treated for bladder cancer can be an extraordinarily frightful and overwhelming time. In addition, even after treatment, the monitoring for cancer recurrence and progression or the ramifications of having a stoma or using a catheter, can be taxing on your mood and quality of life.

Remain active by continuing to ask questions, keeping up to speed on your appointments, and be sure to reach out for support—you are not alone, and you can get through this.

Sources:

Abt D, Bywater M, Engeler DS, Schmid HP. Therapeutic options for intractable hematuria in advanced bladder cancer. Int J Urol. 2013 Jul;20(7):651-60.

American Cancer Society. May 2016. Treating Bladder Cancer.

Babjuk et al. EAU Guidelines on non-muscle-invasive urothelial carcinoma of the bladder: Update 2016. Eur Urol. 2017 Mar;71(3):447-61.

Chang et al. Diagnosis and treatment of non-muscle invasive bladder cancer: AUA/SUO guideline. J Urol. 2016 Oct;196(4):1021-9.

Stephenson AJ. December 2016. Overview of the initial approach and management of urothelial bladder cancer. In: UpToDate, Lerner SP, Ross ME (Eds), UpToDate, Waltham, MA.

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