The bladder is an expandable, hollow organ in the pelvis that stores urine (the body’s liquid waste) before it leaves the body during urination. The urinary tract is made up of the kidneys, ureters, bladder, and urethra and is lined with a layer of cells called the urothelium. This layer of cells is separated from the muscularis propria (bladder muscles) by the lamina propria (a thin, fibrous band).
Bladder cancer is a cancerous tumor that begins when cells in the bladder become abnormal and grow uncontrollably, forming a mass of tissue. It is described as either noninvasive or invasive. Noninvasive cancer does not spread through the lamina propria, and invasive cancer can spread through the lamina propria. Noninvasive cancer may also be called superficial cancer, although that term is being used less often because it may incorrectly imply that this type of cancer is not serious. Invasive cancer is subdivided as either cancer that only grows into the lamina propria or cancer that grows into the muscle layer.
There are three main types of bladder cancer, depending on the type of cell where the cancer begins:
Urothelial carcinoma. Urothelial carcinoma is a new term for this type of bladder cancer. It was previously called transitional cell carcinoma or TCC. Urothelial carcinoma accounts for about 90% of all bladder cancers and begins in the urothelium. A tumor of this type may be described further using one of the four subcategories explained below.
Noninvasive/superficial urothelial carcinoma. This subtype of urothelial carcinoma is limited to the urothelium and is noninvasive. It may spread into the lamina propria beneath the transitional cells. This is sometimes called invasive, though it is not the deeply invasive type that can spread to the muscle layer.
Deeply invasive urothelial carcinoma (often called invasive urothelial carcinoma). This subtype of urothelial carcinoma spreads to the bladder's muscularis propria and sometimes to the fatty layers or surrounding tissue outside the muscle.
Papillary urothelial carcinoma. Papillary is a word that describes a growth that is like a small polyp or flower-shaped cluster of cancer cells. A noninvasive papillary tumor grows into the hollow center of the bladder on a stalk. Invasive papillary urothelial carcinoma can spread into the muscle layer.
Flat urothelial carcinoma. Noninvasive flat urothelial carcinoma (also called carcinoma in situ, or CIS) grows in the layer of cells closest to the inside of the bladder and appears as flat lesions on the inside surface of the bladder. Invasive flat urothelial carcinoma may invade the deeper layers of the bladder, particularly the muscle layer.
Squamous cell carcinoma. This type accounts for about 4% of all bladder cancers and starts in squamous cells, which are thin, flat cells.
Adenocarcinoma. This type accounts for about 2% of all bladder cancers and begins in glandular cells.
All three major types of bladder cancer can metastasize (spread) beyond the bladder. If the tumor has spread into the surrounding organs (the uterus and vagina in women, the prostate in men, and/or nearby muscles), it is called locally advanced disease. The area outside of these organs where bladder cancer usually spreads is the lymph nodes in the pelvis. If it has spread into the liver, bones, lungs, or other parts of the body, these are distant metastases and the cancer may be called advanced disease.
There are other, less common types of cancer that arise in the bladder, including sarcoma (which begins in the muscle layers of the bladder) and small cell anaplastic cancer (a rare type of bladder cancer that is likely to spread to other parts of the body).
Statistics
In 2009, an estimated 70,980 adults (52,810 men and 18,170 women) will be diagnosed with bladder cancer in the United States. It is estimated that 14,330 deaths (10,180 men and 4,150 women) from this disease will occur this year. Among men, bladder cancer is the fourth most common cancer and the eighth most common cause of cancer death.
For people with noninvasive/superficial urothelial carcinoma, the five-year relative survival rate (the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases) is 93%. Seventy-four percent (74%) of people are diagnosed with this stage. If the cancer has spread to the lymph nodes or nearby organs, the five-year survival rate is 45%. If the cancer has spread to distant parts of the body, the five-year relative survival rate is 6%.
Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with bladder cancer. Because the survival statistics are measured in five-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer.
Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2009.
A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices.
The following factors may raise a person’s risk of developing bladder cancer:
Smoking. The most common risk factor is cigarette smoking. Smokers are four to seven times more likely to develop bladder cancer than nonsmokers.
Age. The likelihood of being diagnosed with bladder cancer increases with age.
Gender. Men are three to four times more likely to develop bladder cancer than women, but women are more likely to die from bladder cancer than men. Before smoking rates for women increased to approach smoking rates for men, men were five to six times more likely to develop bladder cancer.
Race. White people are more than twice as likely to be diagnosed with bladder cancer as black people, but black people are twice as likely to die from the disease.
Chemicals. Chemicals used in textile, rubber, leather, dye, paint or print industries, some naturally occurring chemicals, and chemicals called aromatic amines can increase the risk of bladder cancer.
Chronic bladder problems. Bladder stones and infections may increase the risk of bladder cancer. Bladder cancer may be more common for people who are paralyzed from the waist down who have had repeated urinary infections.
Cyclophosphamide (Cytoxan, Clafen, Neosar) use. People who have taken the chemotherapy drug cyclophosphamide have a higher risk of developing bladder cancer.
Personal history. People who have already had bladder cancer are more likely to develop bladder cancer again.
Fluid intake. People who do not drink enough liquids on a regular basis may have a higher risk of bladder cancer.
Schistosomiasis. People who have some forms of this parasitic disease (found particularly in parts of Africa and the Mediterranean region) are more likely to develop bladder cancer.
People with bladder cancer may experience the following symptoms. Sometimes, people with bladder cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. Bladder cancer usually does not cause symptoms that specifically indicate cancer. Most often, bladder cancer is diagnosed when a person tells his or her doctor about hematuria (blood in the urine). General urine tests are not used to make a specific diagnosis of bladder cancer, because hematuria can be a sign of several other conditions besides bladder cancer, such as an infection or kidney stones. One type of urine test that can indicate the presence of cancer is cytology, a test in which the urine is studied under a microscope to look for cancer cells (see Diagnosis).
If you are concerned about a symptom on this list, please talk with your doctor.
Hematuria
Pain during urination
Frequent urination
Feeling the need to urinate many times throughout the night
Feeling the need to urinate, but not being able to pass urine
Symptoms of advanced bladder cancer may include pain, a change in bowel habits, unexplained loss of appetite, and weight loss.
Sometimes when the first symptoms of bladder cancer appear, the cancer has already spread to another part of the body. In this situation, the symptoms depend on where the cancer has spread. For example, cancer that has spread to the lungs may cause a cough or shortness of breath, spread to the liver may cause abdominal pain or jaundice (yellowing of the skin and whites of the eyes), and spread to the bone may cause bone pain or fractures.
Doctors use many tests to diagnose cancer and determine if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
The type of cancer suspected
Severity of symptoms
Previous test results
The earlier bladder cancer is found, the better the chance for successful treatment. However, there is not yet a test that is accurate enough to screen the general population for bladder cancer, so most people are diagnosed with bladder cancer once they have symptoms. As a result, some patients have more advanced disease when the cancer is first found, although more than 70% of those diagnosed have noninvasive bladder cancer.
The following tests may be used to diagnose bladder cancer:
Physical examination. A doctor can sometimes detect lumps in the wall of the bladder by examining the rectum and the pelvis. Areas where the cancer has spread may also be found during a physical examination.
Cystoscopy and biopsy. The doctor places a cystoscope (a small, hollow viewing tube) through the urethra (urinary opening) to look into the bladder. If abnormal tissue is detected, the doctor will do a biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed during the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).
Urine tests. The doctor tests a urine sample to determine if it contains tumor cells. If a patient is undergoing a cystoscopy (see above), an additional test may be performed that involves rinsing the bladder and collecting the liquid through the cystoscope or through another small tube that is inserted into the urethra. The sample can be tested in a variety of ways. The most common way is to look at the cells under a microscope, called urinary cytology. Urine passed out of the body during normal urination can also be examined by cytology. There are other urine cancer tests using molecular analysis that can be done with or instead of urinary cytology.
Intravenous pyelogram (IVP), also called intravenous urogram (IVU). In this x-ray test, a dye containing iodine is injected into a patient’s vein and filtered through the kidneys. The dye enters the urine. This helps the bladder to appear more clearly on an x-ray and can provide an outline of a tumor in the bladder wall. The patient should tell the staff giving this test if he or she is allergic to iodine or other contrast mediums (special dyes).
Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows abnormalities or tumors. Sometimes, a contrast medium is injected into a patient’s vein to provide better detail. The patient should tell the staff giving this test if he or she is allergic to iodine or other contrast mediums.
Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.
One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
How large is the primary tumor and where is it located? (Tumor, T)
Has the tumor spread to the lymph nodes? (Node, N)
Has the cancer metastasized to other parts of the body? (Metastasis, M)
Tumor. Using the TNM system, the "T" plus a letter and/or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. If there is more than one tumor, the lowercase letter "m" (multiple) is added to the "T" stage category. Specific tumor stage information is listed below.
TX: The primary tumor cannot be evaluated due to a lack of information.
T0: There is no evidence of a primary tumor in the bladder.
Ta: This refers to noninvasive papillary carcinoma. Cancer cells are grouped together and can often be easily removed.
Tis: This stage is carcinoma (cancer) in situ, or "flat tumor." This means that the cancer is only found in cells within the lining of the bladder. The doctor may also call it noninvasive/superficial bladder cancer or noninvasive flat carcinoma (the cancer is on or near the surface of the bladder). This type of bladder cancer often comes back after treatment, usually as another noninvasive cancer in the bladder.
T1: The tumor has spread to the subepithelial connective tissue (the tissue below the membrane or covering of the bladder).
T2: The tumor has spread to the muscle.
T2a: The tumor has spread to the inner half of the muscle (which may be called the superficial muscle.)
T2b: The tumor has invaded the deep muscle of the bladder (the outer half of the muscle).
T3: The tumor has grown into the perivesical tissue (the fatty tissue that surrounds the bladder).
T3a: The tumor has grown into the perivesical tissue, as seen through a microscope.
T3b: The tumor has grown into the perivesical tissue macroscopically, meaning that the tumor (s) is large enough to be seen during imaging tests or to be seen or felt by the doctor.
T4: The tumor has spread to any of the following: the abdominal wall, the pelvic wall, a man’s prostate, or a woman’s uterus or vagina.
T4a: The tumor has spread to the prostate, uterus, or vagina.
T4b: The tumor has spread to the pelvic wall or the abdominal wall.
Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the bladder, within the true pelvis (called hypogastric, obturator, iliac, perivesical, pelvic, sacral, and presacral nodes), are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.
NX: The regional lymph nodes cannot be evaluated due to a lack of information.
N0: The cancer has not spread to the regional lymph nodes.
N1: The cancer has spread to a single lymph node, with the size of its largest area being 2 centimeters (cm) or smaller.
N2: The cancer has spread to a single lymph node, with a size greater than 2 cm but no more than 5 cm in its largest area. Or, the cancer has spread into more than one lymph node, with the size of each metastasis being 5 cm or smaller at its largest point.
N3: The cancer has spread to at least one lymph node that measures more than 5 cm at its largest point.
Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body.
MX: Distant metastasis cannot be evaluated.
M0: The disease has not metastasized.
M1: There is distant metastasis.
Grading
Tumor grade. In addition to the TNM system, the cancer may also be evaluated and assigned a grade (G). Doctors use the term grade to describe how much the tumor tissue appears like normal bladder tissue. The grade of a cancer can give the doctor an idea of how quickly the cancer may grow and spread. It is determined by looking at the tumor cells under a microscope. Normal bladder tissue usually has different types of cells grouped together, called differentiated tissue. Cancerous bladder tissue is made up of cells that look more similar to each other. This is less differentiated tissue and looks less like normal bladder tissue. In general, the more differentiated the bladder cancer tissue, the better the prognosis.
GX: The tumor grade cannot be identified.
G1: The cells look more like normal bladder tissue cells (well differentiated).
G2: The cells are somewhat different (moderately differentiated).
G3: The cells are unlike normal bladder tissue cells (poorly differentiated)
G4: The tumor cells do not resemble normal cells (undifferentiated).
Recently, some doctors have tried to simplify the grading system by making the categories more distinct, and replacing four grades with three:
G1: Well-differentiated
G2: Moderately differentiated
G3: Poorly differentiated/undifferentiated
The World Health Organization (WHO) recommends changing bladder cancer grading to only two categories (well-differentiated and poorly differentiated), but this new grading system is not yet widely used.
Cancer stage grouping
Doctors assign the stage of the bladder cancer by combining the T, N, and M classifications.
Stage 0a: This is an early cancer that is only found on the surface of the inner (inside) lining of the bladder. Cancer cells are grouped together and can often be easily removed. The cancer has not invaded the muscle or connective tissue of the bladder wall. This type of bladder cancer is also called noninvasive papillary urothelial carcinoma (Ta, N0, M0).
Stage 0is: This stage of cancer, also known as flat or carcinoma in situ, is found only on the inner lining of the bladder. It has not grown in toward the hollow part of the bladder, and it has not spread to the thick layer of muscle or connective tissue of the bladder. This is always a high-grade cancer (see above) (Tis, N0, M0).
Stage I: The cancer has grown through the inner lining of the bladder to the lamina propria. It has not spread to the thick layer of muscle in the bladder wall. It has not spread to the lymph nodes or any other organs (T1, N0, M0).
Stage II: The cancer has spread into the thick muscle wall of the bladder (also called invasive cancer). It has not reached the fatty tissue surrounding the bladder and has not spread to the lymph nodes or other organs (T2, N0, M0).
Stage III: The cancer has spread throughout the muscle wall to the fatty layer of tissue surrounding the bladder. It may also have spread to the prostate (in men) or the uterus and vagina (in women). It has not spread to the lymph nodes or other organs (T3 or T4a, N0, M0).
Stage IV: The tumor has spread through the bladder wall into the walls of the abdomen or pelvis, and/or it has spread to nearby lymph nodes. It may also be found in parts of the body far away from the bladder, such as the bones, liver, or lungs (any T, any N, M1).
Recurrent cancer: Recurrent cancer is cancer that comes back after treatment. It may come back where is first began or in another part of the body.
Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.
The treatment of bladder cancer depends on the size and location of the tumor, whether the cancer has spread, and the person’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan.
This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials section.
Early-stage bladder cancer can often be treated locally (treatments that just involve the bladder) without removing the whole bladder. More advanced bladder cancer is often treated with systemic chemotherapy (see below). In advanced bladder cancer, it may or may not be necessary to remove the bladder during surgery. Radiation therapy may also be used as an alternative to bladder removal. Each type of treatment is described in more detail below:
Surgery
There are different types of surgery for bladder cancer treatment, depending on the stage of the disease. Surgical options include the following:
Transurethral resection of the bladder (TURB) with fulguration. This procedure is often used with early-stage cancer. The surgeon inserts a cystoscope (see Diagnosis) 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 more advanced (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 is beneficial. In some situations, only part of the bladder may be removed, called a partial or segmental cystectomy.
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 a neobladder, in which case 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; no urinary pad is necessary. The patient drains the pouch periodically 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 discuss the details of their surgery with their doctor to understand exactly what side effects may occur. In general:
TURB may cause mild bleeding and discomfort after surgery.
Following cystectomy and urinary diversion surgery, patients may have infections or urine leaks, and if a neobladder is created, they may sometimes be unable to urinate or completely empty the bladder.
If the bladder is removed (cystectomy), men may be unable to have an erection after surgery (called impotence). Sometimes, a nerve-sparing cystectomy can be performed. When this is done successfully, men may be able to have a normal erection.
Sometimes surgery damages the nerves in the pelvis and causes 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 increase survival.
For some patients, certain chemotherapy and radiation therapy treatment plans may be an alternative to 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.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. 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.
Doctors may use radiation therapy to treat bladder cancer that has invaded the bladder muscle in several ways:
After surgery, to destroy any remaining tumor
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, upset stomach, 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.
Immunotherapy
Immunotherapy (also called biologic therapy) is designed to boost the body’s natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to bolster, target, or restore immune system function. The most common immunotherapy drug for bladder cancer is BCG. A weakened bacterium called bacillus Calmette-Guerin (BCG), which is similar to a form of the germ that causes tuberculosis, 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 can cause flu-like symptoms, chills, mild fever, fatigue, a burning sensation in the bladder, and bleeding from the bladder. Interferon, another immunotherapy drug that can be given as intravesical therapy, is sometimes combined with BCG if the disease does not respond initially to BCG alone.
Chemotherapy
Chemotherapy is the use of drugs to kill cancer cells. For bladder cancer, doctors may decide to use one of two types of chemotherapy: intravesical (local) or systemic (whole body) treatment. In general, earlier-stage cancer is more likely to be treated with local chemotherapy and more advanced cancer with systemic chemotherapy. Chemotherapy may be given before or after surgery. Chemotherapy before surgery is used most often for patients with very widespread or invasive cancer. However, some doctors may perform surgery first and then decided on whether treatment with chemotherapy will be beneficial based on an analysis of the tumor tissue. Patients should talk with their doctor about chemotherapy before surgery.
The types of chemotherapy most often used for bladder cancer are described below:
Intravesical therapy. In this type of therapy, drugs are placed into the bladder through a catheter inserted in the bladder through the urethra. Local treatment kills only noninvasive tumor cells. It cannot reach tumor cells in the bladder wall or that have spread to other organs. The most common drug that is given as intravesical treatment is an immunotherapy drug called BCG (see above). However, other types of drugs are also used. The most common is mitomycin C (Mutamycin). The drugs thiotepa (Thioplex) and doxorubicin (Adriamycin) have also been used.
Systemic chemotherapy. In this type of chemotherapy, patients receive drugs orally (by mouth) or intravenously (given through an IV). Intravenous chemotherapy is injected directly into a vein. Either way, the drugs enter the bloodstream and travel to all parts of the body.
The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.
For bladder cancer, many of the available chemotherapy regimens are still being tested in clinical trials to help determine which drugs, or which drug combinations, work best to treat bladder cancer. Of the known drugs, usually a combination of drugs works better than one drug alone. The question of whether and in what situations it is best to give chemotherapy before or after surgery is also being tested in clinical trials.
A combination of drugs, called MVAC, has been used as the standard treatment for bladder cancer for many years, based on the results of clinical trials from the 1990s. 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), doxorubicin, and cisplatin (Platinol). This combination with the addition of other drugs, such as paclitaxel (Taxol), docetaxel (Taxotere), and ifosfamide (Ifex), is also being studied in clinical trials. The combination of gemcitabine (Gemzar) plus cisplatin is also used and has similar effects to the MVAC combination but with fewer side effects. Other drugs are now in clinical trials to determine if there is a combination of drugs that works better and has fewer side effects.
Chemotherapy for locally advanced bladder cancer
Locally advanced bladder cancer is invasive bladder cancer that has spread beyond the bladder to nearby organs or to the pelvic lymph nodes. Researchers are studying new combinations of chemotherapy that are more effective in managing bladder cancer. Treatments may include:
Combinations of different drugs
Known 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 through 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 improves survival for patients with invasive bladder cancer. This type of initial chemotherapy, termed 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 it does not appear that single-drug chemotherapy improves the survival of patients with locally advanced bladder cancer.
Chemotherapy for metastatic bladder cancer
Metastatic bladder cancer is cancer that is diagnosed after it has spread beyond the lymph nodes. The term advanced bladder cancer may be used; this can also refer to a cancer that has recurred after all local treatments (such as a cystectomy or radiation therapy) have failed and poses a serious threat to the patient’s survival.
There are no methods to permanently cure metastatic bladder cancer for most people. For these patients, the goals of treatment are to slow the spread of cancer, shrink the tumor (temporary remission), relieve symptoms, and extend life as long as possible. With advances in treatment, most patients with advanced 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 approaches in treatment. Changes to these regimens or the use of new treatment regimens that improve survival rates, quality of life, and duration 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. Clinical trials compare the best treatments available (standard treatments) with newer treatments that may be more effective. Investigating new treatments involves careful monitoring using scientific methods, and all participants are followed closely to track progress.
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. Learn more about your prescriptions through Cancer.Net’s Drug Information Resources, which provides links to searchable drug databases.
Doctors and scientists are always looking for better ways to treat patients with bladder cancer. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress is treating bladder cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with bladder cancer.
To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about Clinical Trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.
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 do occur.
Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health.
Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during or after treatment. For more information on the most common side effects of cancer and different treatments, along with ways to prevent or control them, visit Cancer.Net’s section on Managing Side Effects>Managing Side Effects, based on ASCO’s curriculum.
In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing these needs in Cancer. Net’s section on Caring for the Whole Patient.
For more information on late effects or long-term side effects, please read the After Treatment section or talk with your doctor.
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 functioning properly 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 other medical conditions.
For patients with a urinary diversion, follow-up care may include checking for infection with urine tests, checking and correcting problems with urinary continence (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. Learn more about Healthy Living After Cancer.
Research for bladder cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor.
Laparoscopic cystectomy. In laparoscopic surgery, the surgeon makes several small incisions, instead of the one larger incision used in traditional surgery. The surgeon uses telescoping equipment to remove the bladder. This surgery may take longer, but it is less painful afterward and patients recover more quickly. Several studies are in progress to determine whether laparoscopic cystectomy is as safe as the standard “open” surgical approach 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, which collects in the tumor for a few days. The doctor then focuses a special laser light on the cancer, which changes the collected chemical 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 faulty genes or proteins that contribute to cancer growth and development. New treatments based on what is known about genetics and how changes in genes cause cancer to develop are already available for some cancers. Research is underway to determine how this approach may be useful in treating bladder cancer.
New chemotherapy/combinations. As described in the Treatment section, researchers are investigating new drugs and new combinations of chemotherapy.
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
General questions
What type of bladder cancer do I have?
Is it noninvasive or invasive? What does this mean?
Can you explain my pathology report (laboratory test results) to me?
What is the stage of my cancer? What does this mean?
What are my treatment options?
What clinical trials are open to me?
What treatment plan do you recommend? Why?
What is the goal of this treatment?
What are the possible side effects of this treatment, both in the short term and the long term?
How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
Do I need treatment right away?
For patients who need surgery
Will my entire bladder be removed?
Do you have experience with making urinary reservoirs, and can I have that type of surgery?
What are the possible side effects of my surgery, in the short term and the long term?
Will I need to stay in the hospital for this surgery? If so, for how long?
Will this surgery affect my sex life?
Will this surgery affect my fertility (ability to bear children)?
For patients who need chemotherapy/immunotherapy
What type of therapy will I be receiving?
How will it be delivered (through an IV, a catheter, or a pill)?
What does the preparation for this treatment involve?
What side effects can I expect from this treatment?
What can be done to relieve the side effects?
For patients who need radiation therapy
What type of radiation therapy is recommended?
What is the goal of the radiation therapy?
How long will it take to give the radiation therapy?
What side effects can I expect from this treatment?
What can be done to relieve the side effects?
After treatment
What are the chances that the tumor will return?
What follow-up tests will I need, and how often will I need them?
What support services are available to me? To my family?
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