How is bladder cancer treated?
Your treatment options for bladder cancer depend on a number of factors, including the type and stage of the cancer, your overall health, and your treatment preferences. Discuss your options with your doctor to determine what treatments are best for you.
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. 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.
General bladder cancer treatment information
Once your cancer has been diagnosed and staged, there is a lot to think about before you and your doctor choose a treatment plan. You may feel that you must make a decision quickly, but it is important to give yourself time to absorb the information you have just learned. Ask your cancer care team questions.
You will want to weigh the benefits of each treatment option against the possible risks and side effects. The best treatment for you will depend on the type and stage of your bladder cancer as well as your general health, age, and personal preferences.
If time permits, you might want to get a second opinion about your best treatment option. This can be especially helpful if you have several treatment choices. A second opinion can provide more information and help you feel more confident about the treatment plan you choose.
Main types of treatment for bladder cancer
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:
• 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.
• 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. 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.
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 (see Diagnosis of Bladder Cancer) 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.
Intravesical therapy
With intravesical therapy, the doctor puts a liquid drug directly into the bladder (through a catheter) rather than giving it by mouth or injecting it into a vein. This could be either immunotherapy, which causes the body’s own immune system to attack the cancer cells, or chemotherapy.
Medicines given this way mainly affect the cells lining the inside of the bladder, with little to no effect on cells elsewhere. This means that any cancer cells outside of the bladder lining, including those that have grown deeply into the bladder wall, are not treated. Drugs put into the bladder also can’t reach cancer cells in the kidneys, ureters, and urethra, or those that have spread to other organs.
For this reason, intravesical therapy is used only for non-invasive (stage 0) or minimally invasive (stage I) bladder cancers.
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.
Surgery
• 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) 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.
• 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.
• 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. 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.
• 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.
Treatment for Bladder Cancer
Learn more about Bladder Cancer