Treatment

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.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment.