Bladder CancerLast Updated: July 18, 2011 This section has been reviewed and approved by the Cancer.Net Editorial Board, 04/11 Overview
About the bladder 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). About bladder cancer Bladder cancer begins when normal cells in the bladder change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning is can spread to other parts of the body). 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. Noninvasive bladder cancer is less likely to spread and can often be managed with surgery to remove tumors and chemotherapy (see Treatment). Invasive cancer is subdivided as either cancer that only grows into the lamina propria or cancer that grows into the muscle layer. Both invasive and noninvasive bladder cancers have the possibility of spreading into the bladder muscle or to other parts of the body. Types of bladder cancer 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. Non-muscle-invasive/superficial urothelial carcinoma. This subtype of urothelial carcinoma is located only in the urothelium and is non-muscle-invasive, meaning it has not invaded the muscle layer. It may invade 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. Muscle-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 lamina propria or 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. Bladder cancer can also often spread to the lymph nodes in the pelvis. If it has spread into the liver, bones, lungs, lymph nodes outside the pelvis, or other parts of the body, these are distant metastases and the cancer is called metastatic or advanced disease. There are other, less common types of cancer that begin 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). Find out more about basic cancer terms used in this section. Looking for More of an Overview? If you would like additional introductory information, explore the following item on Cancer.Net:
Or, choose “Next” (below, right) to continue reading this detailed section. To select a specific topic within this section, use the icon panel located on the right side of your screen. Statistics
This year, an estimated 69,250 adults (52,020 men and 17,230 women) will be diagnosed with bladder cancer in the United States. It is estimated that 14,990 deaths (10,670 men and 4,320 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. The five-year survival rate is the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases. This rate depends on many factors, including the stage of bladder cancer that is diagnosed. For people with non-muscle-invasive/superficial urothelial carcinoma, the five-year survival rate is 97%. About half of people are diagnosed with this stage. If the tumor is invasive but has not yet spread outside the bladder, the five-year survival rate is 73%. If the cancer has spread to the lymph nodes or nearby organs, the five-year survival rate is 36%. If the cancer has spread to distant parts of the body, the five-year survival rate is 6%. Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with 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. Learn more about understanding statistics. Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2011. Medical Illustrations
Our staging illustrations are currently being updated to comply with the new 2010 American Joint Committee on Cancer staging guidelines. We apologize for the inconvenience. Risk Factors
A risk factor is anything that increases a person’s chance of developing cancer. 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 talking about them with 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. Learn more about tobacco’s link to cancer and how to quit smoking. Age. The likelihood of being diagnosed with bladder cancer increases with age. More than 70% of people with bladder cancer are older than 65 years old. 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, men were five to six times more likely to develop bladder cancer than women. 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 and have had many 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 regularly drink enough liquids 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. Arsenic. Arsenic is a naturally-occurring substance that can cause health problems in large amounts. In drinking water, it has been associated with an increased risk of bladder cancer. The chance of being exposed to arsenic depends on where you live and whether you get your water from a well or from a system that meets the standards for acceptable arsenic levels. Symptoms and Signs
People with bladder cancer may experience the following symptoms or signs. 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 blood in the urine, also called hematuria. General urine tests are not used to make a specific diagnosis of bladder cancer, because hematuria can be a sign of several other conditions that are not 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 or sign on this list, please talk with your doctor.
Symptoms of advanced bladder cancer may include pain, unexplained appetite loss, 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 bone breaks. Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often. If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms. Diagnosis
Doctors use many tests to diagnose cancer and find out 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:
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 most people 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 TURBT. This test allows the doctor to see inside the body with a thin, lighted, flexible tube called a cystoscope. The patient is sedated as the tube is inserted through the urethra (urinary opening) and into the bladder. If abnormal tissue is found, the doctor will do a biopsy. This procedure is called a transurethral bladder tumor resection or TURBT. During a TURBT, the doctor can remove the tumor and a sample of the bladder muscle near the tumor. A TURBT is used to diagnose bladder cancer and find out how deeply it has grown into the layers of the bladder. After the TURBT is done, the urologist will also evaluate the bladder to see if any masses can be felt in the bladder. This is called an exam under anesthesia or EUA. 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). A TURBT is also a treatment for a non-muscle-invasive tumor (see Treatment for more information). Urine tests. The doctor tests a urine sample to find out 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 tests using molecular analysis that can be done to help find cancer, usually at the same time as urinary cytology. 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 (special dye) is injected into a patient’s vein to provide better detail. The patient should tell the staff giving this test beforehand 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. Learn more about what to expect when having common tests, procedures, and scans. After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging. Learn more about the first steps to take after a diagnosis of cancer. Staging
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and whether 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. The stage of bladder cancer is determined based on the results of the sample removed during a TURBT (see Diagnosis) and whether the cancer has spread to other parts of the body, which is determined by imaging tests, a physical examination, and laboratory tests. One tool that doctors use to describe the stage is the TNM system. This system judges three factors: 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 of bladder cancer: 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:
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. 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 non-muscle-invasive/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 of the bladder wall. T2a: The tumor has spread to the inner half of the muscle of the bladder wall (which may be called the superficial muscle.) T2b: The tumor has spread to 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 seminal vesicle (the tube(s) that carry semen), 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 lymph 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. N0: The cancer has not spread to the regional lymph nodes. N1: The cancer has spread to a single regional lymph node in the pelvis. N2: The cancer has spread to more than one regional lymph node in the pelvis. N3: The cancer has spread to the common iliac lymph nodes, which are located behind the major arteries in the pelvis, above the bladder. Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body. M0: The disease has not metastasized. M1: There is distant metastasis. 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 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 (Tis, N0, M0). This is always a high-grade cancer (see Grading, below). 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 or to lymph nodes or other organs (T1, N0, M0). Stage II: The cancer has spread into the thick muscle wall of the bladder (also called invasive cancer or muscle-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: Any of these conditions:
Recurrent cancer: Recurrent cancer is cancer that comes back after treatment. If there is a recurrence, the cancer may need to be staged again (re-staging) using the system above. 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 abnormal cells that look more similar to each other. This is called less-differentiated tissue and looks less like normal bladder tissue. In general, the more differentiated the bladder cancer tissue, the better the prognosis. Many urological surgeons classify grading based on the chance that the cancer will recur (come back after treatment) or progress (grow and spread), and plan their treatment based on the grade, using the following categories: Papilloma. Benign papillary urothelial neoplasm of low malignant potential (PUNLMP). These types of cancer may recur but have a low risk of progressing. Low grade. These types of cancer are more likely to recur and progress compared with PUNLMP. High grade. These types of cancer are most likely to recur and progress compared with low grade tumors and PUNLMP. More recently, the World Health Organization (WHO) has recommended changing bladder cancer grading to only two categories: 1) well-differentiated or low grade, and 2) poorly differentiated or high grade. This is the system that is used in the latest version of the American Joint Committee on Cancer (AJCC) Staging System. In the past, grading was classified as four groups, but was changed to two groups because the four grades were not different enough to help doctors plan treatment. Treatment decisions should be based on two major groups – cancer that is less likely to recur and cancer that is more likely to recur. Used with permission of the AJCC, Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer-Verlag New York, www.cancerstaging.net. Treatment
This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether 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 and Current Research sections. Treatment overview 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. 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 instead of removing the bladder. Learn more about making treatment decisions. Surgery Surgery is the removal of the tumor and surrounding tissue during an operation. There are different types of surgery for bladder cancer treatment, depending on the stage of the disease. A urologist or urologic oncologist is a doctor who specializes in treating bladder cancer using surgery. Surgical options to treat bladder cancer include the following: 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 (see below). During TURBT, 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 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. 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. 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:
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.
Learn more about cancer surgery. 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 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:
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. Learn more about radiation therapy. 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. BCG is often given as three one-week treatment cycles every six months for three years. Before BCG treatment, patients will need to have another TURBT (see above) to make sure that the cancer has not spread to the muscle. BCG treatment may help patients avoid a cystectomy. 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) another immunotherapy drug that can be given as intravesical therapy, is sometimes combined with BCG if BCG alone does not help treat the cancer. Learn more about immunotherapy. Chemotherapy Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen usually 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 or after 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: Intravesical therapy. 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 (see Immunotherapy above). However, other types of drugs are also used. The most common is mitomycin C (Mitozytrex, Mutamycin). The drugs thiotepa (multiple brand names) and doxorubicin (Adriamycin) have also been used. Systemic chemotherapy. 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 chemotherapy regimens are still being 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 (Gemzar) 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 works better and has 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. 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:
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 it is considered the 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. Learn more about chemotherapy and preparing for treatment. 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 by using searchable drug databases. Recurrent bladder cancer Once your treatment is complete and there is a remission (absence of cancer symptoms; also called “no evidence of disease” or NED), talk with your doctor about the possibility of the cancer returning. Many survivors feel worried or anxious that the cancer will come back. Learn more about coping with this fear. If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, chemotherapy, and radiation therapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence. Metastatic bladder cancer If the cancer has spread to another location in the body other than the pelvic lymph nodes, it is called metastatic cancer. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials studying new treatments. Your health care team may recommend a combination of treatments to help manage the cancer. There are no methods to permanently cure metastatic bladder cancer for most people. The goals of treatment are to slow the spread of cancer, shrink the tumor (called 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 treatments for patients who are healthy enough to receive such therapy. There are other drugs and combinations that can be used for patients who for medical reasons are unable to receive gemcitabine-cisplatin or MVAC. Changes to these regimens or the use of new treatment regimens that help patients live longer and improve their quality 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. In addition to treatment to slow, stop, or eliminate the cancer (also called disease-directed treatment), an important part of cancer care is relieving a person’s symptoms and side effects. It includes supporting the patient with his or her physical, emotional, and social needs, an approach called palliative or supportive care. People often receive disease-directed therapy and treatment to ease symptoms at the same time. If disease-directed treatment is not successful, this may also be called advanced cancer. This diagnosis is stressful, and it may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Learn more about advanced cancer care planning. Find out more about common terms used during cancer treatment. About Clinical Trials
Doctors and scientists are always looking for better ways to treat patients with bladder cancer. To make scientific advances, doctors create research studies involving people, called clinical trials. Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often 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. There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease. 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 these studies are 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. Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials. To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that 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 clinical trials. For specific topics being studied for bladder cancer, learn more in the Current Research section. Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends. Side Effects
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 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 your overall health. Common side effects for each treatment option are described in detail within the Treatment section. 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. Also, be sure to communicate with the doctor about side effects you experience during or after treatment. Care of a patient’s symptoms and side effects is an important part of a person’s overall treatment plan; this is called palliative or supportive care. It helps people with cancer at any stage of illness be as comfortable as possible. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Be sure to talk with your doctor about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with bladder cancer. Learn more about caregiving. In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. For many patients, a diagnosis of bladder cancer is stressful and can bring difficult emotions. Patients and their families are encouraged to share their feelings with a member of their health care team, who can help with coping strategies. Learn more about the importance of addressing such needs, including concerns about managing the cost of your cancer care. A side effect that occurs more than five years after treatment is called a late effect. Treatment of late effects is an important part of survivorship care. Learn more about late effects or long-term side effects by reading the After Treatment section or talking with your doctor. After Treatment
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. ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is complete. 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 working well 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 another medical condition. For patients with a urinary diversion, follow-up care may include checking for infection with urine tests, checking and fixing problems with 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 the next steps to take in survivorship, including making positive lifestyle changes. Find out more about common terms used after cancer treatment is complete. Current Research
Doctors are working to learn more about bladder cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you. Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. For bladder cancer, research indicates that a PET scan may help find bladder cancer that has spread better than a CT scan or MRI alone. Laparoscopic cystectomy. Several studies are underway to find out whether laparoscopic cystectomy (see Treatment) is as safe as the standard surgery 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 that collects in the tumor for a few days. Then, the doctor focuses a special laser on the cancer, which changes the chemical in the tumor 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 the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to normal cells, usually leading to fewer side effects than other cancer medications. Research is underway to determine how targeted therapy may be used to treat bladder cancer. For instance, a clinical trial is looking at combining targeted therapy with radiation therapy to help preserve bladder function. New drugs and drug combinations. As described in the Treatment section, researchers are studying new drugs and new combinations of chemotherapy. Supportive care. Clinical trials are underway to find better way of reducing symptoms and side effects of current bladder cancer treatments in order to improve patients’ comfort and quality of life. Learn more about common statistical terms used in cancer research. Looking for More about Current Research? If you would like additional information about the latest areas of research regarding bladder cancer, explore these related items:
Or, choose “Next” (below, right) to continue reading this detailed section. Questions to Ask The Doctor
Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. General questions
For patients who need surgery
For patients who need chemotherapy/immunotherapy
For patients who need radiation therapy
After treatment
Patient Information Resources
In addition to Cancer.Net, there are other sources of information about this type of cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk with your doctor about questions you may have about information you find about this disease. View organizations that offer information on this specific type of cancer. |
