Bladder Cancer Chemotherapy

December 15, 2021

What is neoadjuvant chemotherapy?

Neoadjuvant chemotherapy is the term used for chemotherapy prior to (before) surgery.  Clinical trials have shown that the use of intravenous chemotherapy before radical cystectomy improves survival for patients with invasive bladder cancer. This type of initial chemotherapy, termed neoadjuvant chemotherapy, works to shrink the tumor within the bladder. It may also kill small metastatic deposits of disease that have spread beyond the bladder. It is important to note that it does not appear that single-agent chemotherapy is helpful in improving the survival of patients with locally advanced bladder cancer. A treatment plan that specifies the dosage, the schedule, and the duration of treatment is called a regimen. The two regimens recommended for neoadjuvant treatment are either dose-dense MVAC or GC (discussed below).

What is adjuvant chemotherapy?

Adjuvant chemotherapy is the term used for chemotherapy following surgery. Typically, removal of the bladder also involves the removal of a number of lymph nodes surrounding the bladder. These are then sent to the pathology lab for analysis. If the pathology results indicate that cancer has spread to the lymph nodes, the doctor may recommend adjuvant chemotherapy to help prevent any cancer recurrence. The goal is to kill any microscopic cancer cells which were not visible at the time of surgery.  Dose Dense MVAC or GC are typically recommended in this setting. If bladder cancer is found to have spread to other sites, beyond the bladder, systemic chemotherapy is recommended. It is very difficult to permanently cure metastatic bladder cancer. In most cases, the goal of treatment is to slow the spread of cancer. It may help shrink the tumor, relieving symptoms, and extending life as long as possible. Chemotherapy can also destroy or cause symptoms in healthy cells in your body. Speak to your medical team about possible side effects that you may experience on different chemotherapy regimens. Your medical team can help you to manage many of those side effects.

What type of chemotherapy is used for bladder cancer?

Cisplatin-based chemotherapy has been the best standard treatment for bladder cancer since the 1970’s. Based on the results of clinical trials from the 1990s, the two regimens most commonly used are dose-dense (DD) MVAC and GC. Chemotherapy goes into the body through a vein. It may be infused with a catheter into a vein or through a port that is placed under the skin, usually in the right side of the chest. MVAC uses four drugs: methotrexate (MTX, Amethopterin, Rheumatrex, Trexall), vinblastine (Velban), doxorubicin (Adriamycin, Rubex), and cisplatin (Platinol). We no have effective anti-nausea medication and injections that can keep immune systems from being depleted by chemotherapy. This has have improved our ability to give MVAC safely on an accelerated dose-dense schedule. The National Comprehensive Cancer Network (NCCN) now recommends MVAC be given according to the “dose-dense or DD” schedule due to improved toxicity and suggested improvement in efficacy compared with the standard schedule. Click here to view the NCCN Guidelines.

A clinical trial conducted in the late 1990s showed that the combination of gemcitabine (Gemzar), plus cisplatin (GC), gives similar anticancer effects to standard MVAC combination. Both GC and DD MVAC have been useful in bladder cancer in delaying recurrence, extending life and sometimes achieving a cure, and both regimens are routinely used in the neoadjuvant and metastatic settings. Clinical trials are underway to assess whether the addition of another agent to these regimens improves outcomes.

The choice of which chemotherapy to use depends on the patients overall health. Evaluating how fit, how strong, or how frail he or she is, can help the medical team decide which treatment to recommend. Click here to watch medical oncologist Dr. Guru Sonpavde, and two patient advocates discuss chemotherapy as a treatment for bladder cancer.

During a recent Understanding Advanced/Metastatic Bladder Cancer webinar, Dr. Alicia Morgans, MD, MPH, of Dana Farber Cancer Institute provided a simple explanation of how chemotherapy works. Click here to watch. 

Is combination chemotherapy and radiation used for bladder cancer treatment?

In recent years, chemotherapy and radiation have been combined to provide a “bladder preservation” therapy for higher risk (i.e. muscle-invasive) cases. In the past radiation therapy alone was used because it effectively shrunk tumors. Bladder cancer tumor cells are chemosensitive, susceptible to the cell-killing effects of anticancer drugs. Adding combined chemotherapy (multiple chemotherapeutic agents given together) to radiation has improved results. To ensure the success of bladder preservation therapy, there are at least three requirements which should be met: 1) “complete” resection of the tumor(s) by TURBT; 2) no obstruction of 1 or both kidneys as a result of the bladder tumor; and 3) no T4 bladder tumors.

If the tumors do not respond to an initial course of chemotherapy and radiation, it may be reasonable to perform, if medically possible, a cystectomy.

Information and services provided by the Bladder Cancer Advocacy Network (BCAN) are for informational purposes only. The information and services are not intended to be substitutes for professional medical advice, diagnosis, or treatment. If you are ill or suspect that you are ill, seek professional medical attention immediately! BCAN does not recommend or endorse any specific physicians, treatments, procedures, or products even though they may be mentioned on this site.