Carlos G. Arcangeli, MD & Mark A. Rosen, MD

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Bladder Cancer Treatment

The treatments for different stages of bladder cancer differ greatly, based on the major differences in their risk of spread or cancer death. Superficial bladder tumors are usually treated with minor, outpatient surgery to remove the tumor, whereas invasive cancers are treated with surgery, chemotherapy, or both. Radiation and chemotherapy can increase the chances for curing invasive bladder cancer, help control metastatic disease, and prevent the disease from recurring, but they are usually not used as the main or only treatment. The following information describes the treatments for the different stages of bladder cancer.

Superficial Bladder Tumors (Ta)

Transurethral Surgery to Remove the Cancer

Most early bladder cancers are biopsied and removed through a cystoscope which is passed through the urethra into the bladder. This is usually referred to as ‘transurethral resection’. This type of removal is effective for superficial cancers which have NOT invaded into the bladder muscle. An electric cutting knife or ‘loop’ attached to the endoscope is used to remove the tumors. In some instances, lasers are being used to destroy bladder tumors. Several tumors may be removed during a single operation and the procedure can be repeated as often as necessary. An anesthetic, such as general anesthesia or spinal, is necessary for any transurethral resection.

Intravesical Therapy

Intravesical therapy refers to medical treatments that are instilled into the bladder through the urethra using a catheter. These procedures are usually done in the office and require only 5 minutes to perform. The tube is removed immediately, but the medications must be kept in the bladder for about two hours. Intravesical therapy is usually used for patients whose tumors have been completely removed but who are at high risk of having recurrences or new tumors develop at a later time. On occasion, intravesical therapy is used to treat multiple bladder tumors that could not be completely removed by surgery. Chemotherapy given directly into the bladder does not usually cause side effects like chemotherapy taken orally or injected into the body. Because the therapy is limited to the bladder most of the side-effects are the irritative effects on the bladder, such as frequency, urgency and burning with urination. Most of these effects dissipate after the treatments are discontinued. The most commonly used and effective medication is called BCG, which is actually a type of immunotherapy, a treatment that stimulates a patient’s immune system to fight off cancer cells. Other currently used drugs include Interferon-A, Thiotepa, Mitomycin-C, and Adriamycin.

Carcinoma-in-situ (CIS)

Carcinoma-in-situ (CIS) is an aggressive form of bladder cancer that has not yet begun to invade or spread. This type of cancer is treated with intra-vesical immunotheraoy. Intra-vesical immunotherapy means that a medication is placed into the bladder that stimulates the immune system to help fight off cancer cells in the bladder. The most effective and commonly used medication is called BCG. BCG is actually an attenuated, or weakened, form of the tuberculosis bacterium. Most patients receive six weekly treatments, which are followed by cystoscopy and urine cytology to look for recurrence of the cancer. Patients who are free of cancer are then usually treated with 3 weeks of “booster” treatments every six months for three years. Patients who have recurrence are sometimes treated with a second six week induction course of BCG. Approximately 75% of patients with CIS are cured by BCG therapy; patients who are not cured can be treated with other types of immuno-therapy, but they should also strongly consider more aggressive bladder surgery or chemotheraqpy to prevent the spread of the cancer.

Superficial Invasive Tumors (T1)

T1 bladder tumors are a potentially serious form of bladder cancer that has been caught early, before it has had a chance to invade the bladder wall or spread to other parts of the body. These tumors can be eliminated with minor surgery, but they can recur as a life-threatening cancer and they deserve very close followup and treatment.

Transurethral resection and Intravesical Therapy

The standard treatment for T1 bladder tumors is initial transurethral resection, just like for superficial (Ta) tumors. All patients with T1 bladder tumors should undergo repeat resection 6 weeks after the first surgery to be certain that there is no more tumor and that the tumor is not a more serious, invasive tumor. Patients who are found to be stage T1 after the second resection are then treated with intra-vesical BCG therapy. Without BDCG treatment the risk of progression to malignant, invasive cancer is 30-40%; after transurethral surgery and BCG therapy the risk of progression to serious cancer is approximately 15%. Patients with T1 tumors need cystoscopy to look for recurrence every 3 months for the first two years after initial diagnosis.

Surgery (Cystectomy)

All patients who have recurrent T1 bladder cancer after BCG therapy should strongly consider surgery to remove the bladder because they face a high risk of development of invasive cancer in the future. The long-term cure rate for patients who have cystectomy for recurrent T1 bladder cancer is 80-90%; if patients wait until they develop an invasive cancer and then undergo surgery the cure rate is 40-50%. Younger patients with larger, high-grade T1 cancers should consider cystectomy as an initial treatment.

Muscle-Invasive Tumors (T2-T4)

Surgery (cystectomy)

Invasive cancer is most commonly treated by major surgery to remove the bladder. If the surgery is done before the cancer spreads outside the bladder wall the chance for cure is high. After removal of the bladder some type of reconstruction must be done to hold the urine. There are three options, called ileal loop urinary diversion, continent catheterizable pouches, and neo-bladders.

Neo-bladders are pouches made out of intestine that hold the urine and are connected to the urethra so that patients can urinate through the urethra. This is the most normal type of reconstruction for most people. Catheterizable pouches are made of intestine and hold urine inside them. The patient passes a catheter through a small opening in the abdominal wall into the pouch to empty the urine. This is ideal for active patients who cannot have a neobladder constructed. The oldest type of reconstruction is an ileal loop diversion. The urine drains through a opening in the abdominal wall into an external bag. This is very safe and may be best for some older patients.

Chemotherapy and Surgery

Recent studies show that chemotherapy given before surgery, called neo-adjuvant chemotherapy, improves the long-term survival rate for bladder cancer. Some urologists and oncologists recommend chemotherapy given after surgery, called adjuvant chemotherapy. There is evidence that adjuvant chemotherapy improves survival of patients with invasive bladder cancer, but it is not proven as well as it is for neo-adjuvant chemotherapy. Patients should discuss the role of chemotherpay with their urologists and oncologists.

Bladder Sparing Chemo-Radiation

Chemotherapy or radiation given individually have not been proven to be effective treatments for bladder cancer, but a combination of chemotherapy and radiation may allow many patients to cure the cancer without the need for major surgery. Most bladder-sparing protocols call for initial chemotherapy for several months, followed by repeat bladder biopsy. If the cancer shows evidence of growth the patients proceed with cystectomy, but if the cancer has responded to chemotherapy then patients will hsave a series of radiation treatments followed by a second round of chemotherapy. Studies show that approximately 50% of patients can survive 5 years and still maintain their bladders with thsi type of therapy, but many patients will go through chemotherapy and radiatian, and still need major bladder surgery. Patients should discuss this type of treatment with their urologists and oncologists before deciding on a treatment plan.