Different types of treatment are available for bladder cancer. Some treatments are standard and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial.
Surgery to remove the bladder is called a cystectomy. Virtually all cystectomies for cancer are radical, meaning that the entire bladder is removed. Partial cystectomies are rare, but may be appropriate for very carefully selected patients. Minimally invasive surgery techniques such as laparoscopy are still considered experimental, and are not routinely performed at this time.
In men, the bladder, prostate and lymph nodes are removed in a cystectomy. Surgical advances are allowing surgeons to spare the nerve bundles responsible for erection. In women, the bladder, uterus and part of the anterior vaginal wall are removed, but the vagina can now be spared in some cases.
For some early-stage or superficial bladder cancers, a procedure called transurethral resection (TUR) may be used. A resectoscope, which is a thin tool with a wire loop on the end, is threaded through the urethra to scrape the tumor from the bladder wall. The resectoscope can also be used to deliver an electrical current to burn the tumor away.
Bladder Reconstruction Surgery
When the bladder is removed, there are procedures known as urinary diversions to restore urinary function. Urinary diversions are done at the same time as a cystectomy. There are three types of urinary diversion:
Ileal neobladder: part of the ileum (small intestine) is used to make a new bladder, allowing for "normal" urination. This procedure works best on men. It provides good daytime urinary control, with about a 20% chance of nighttime incontinence. Some women may have trouble completely emptying the neobladder and may sometimes need to use a catheter.
Ileal conduit: a piece of small intestine is used to create a “pipe” that connects ureters to the surface of the skin in the navel. Urine is directed to a urostomy bag worn on the outside of the body. It is a simple and efficient procedure, but some patients may have issues with wearing an external appliance.
Continent reservoir: intestinal tissue is used to create an internal pouch that is connected to the navel. The patient uses a catheter to drain the pouch. This procedure is done less frequently than the other two.
Chemotherapy plays a major role in the treatment of metastatic bladder cancer that has spread to the lymph nodes, lungs, liver and other parts of the body. In patients who have metastases at diagnosis, chemotherapy is the frontline treatment.
The "gold standard" chemotherapy for metastatic bladder cancer is a combination of four drugs known as MVAC: methotrexate, vinblastine, adriamycin and cisplatin. MVAC has provided good response rates since the 1980s. In recent years, the MVAC treatment regimen has been decreased from four weeks to two weeks, with less toxic side effects for the patient and an improved response rate of 50% and higher.
Another chemotherapy regimen is a combination of gemcitabine and cisplatinum. It is less toxic than MVAC, with similar response rates. Both chemotherapies have an average survival rate of 14 months.
Chemotherapy is also used in conjunction with surgery for patients who are at high risk for metastasis. Data suggest that bladder tumors that have invaded the muscle wall and have the potential to spread can benefit from chemotherapy before surgery (neoadjuvant therapy).
Although surgery is the frontline treatment for bladder cancer, radiation treatment does have a role in certain patients. Simultaneous radiation and chemotherapy with cisplatin may be used instead of surgery in an effort to save the bladder. However, only about 40% of patients who undergo bladder-sparing treatment will be able to keep their bladder and not have the cancer come back.
The best candidates for radiation therapy:
- Have locally resected tumors
- Have only one tumor site
- Can tolerate chemotherapy and 35 radiation treatments
- Must undergo rigorous follow-up after treatment
In recent years, a significant amount of cancer research has been devoted to immunotherapy, which uses the body's own defense mechanisms to fight cancer. All cells have protein markers, called antigens, on their surfaces that identify them as either "normal" or "foreign." The presence of foreign antigens (such as cancer cells) in the body provokes a sophisticated chemical reaction involving lymphocytesand other cells that defend the body against disease. Some of these defender cells produce antibodies, which seek out and destroy specific antigens.
Immunotherapies are designed to manipulate the antigen/antibodyimmune response by targeting antigens on specific types of tumor cells. As researchers identify more of these tumor-specific antigens, they are working to develop therapeutic agents that target only those cells.
Radiation therapy is used with patients with locally advanced disease in combination with chemotherapy with the aim of preserving the bladder, as an adjuvant after surgery in the case of poor prognosic factors in anatomical pathology or to treat symptoms in the case of bleeding.
The following technological means and type of radiation therapy are used with this disease.
- Virtual CT simulation
- Intensity modulated radiation therapy (IMRT)
- Volumetric Modulated Arc Therapy (VMAT)
Immunotherapy & Bladder Cancer
For superficial bladder cancer, another type of immunotherapy has become the standard of care.
Intravesical immunotherapy involves filling the bladder with a solution containing Bacillus Calmette-Guérin (BCG), a bacterial organism that is sometimes used to treat tuberculosis. The BCG, delivered through a catheter, stimulates an immune response within the bladder to destroy any remaining cancer cells. Intravesical immunotherapy is performed after the bladder wall has been scraped to remove superficial tumor cells. The treatment success rate with intravesical BCG is 70% to 80%.