Knowing the stage and grade of your tumor helps your doctor decide which methods are most suitable for treating your cancer. It is important to remember that bladder cancer patients must expect to be closely followed by their urologists, with regularly scheduled cystoscopies and urine cytology as bladder tumors often recur. Early detection is crucial to a good long-term prognosis.
Ta papillary tumors are usually low grade (most closely resemble normal cells) and, even though a large majority will recur multiple times after the initial diagnosis and removal, 85-90% will never invade the bladder wall and become life-threatening. Further treatment beyond removal may not be necessary, but regular follow-up is required.
Although CIS is also non-invasive, as the tumor has not grown into the lamina propria (the layer of blood vessels and cells that is situated between the bladder lining and the muscle wall), it is more aggressive than Ta non-invasive tumors and will probably be treated with more aggressive therapies, including intravesical immunotherapy (BCG). Once the tumor has invaded the lamina propria, it is considered an invasive tumor with the potential of spreading through the muscle wall and ultimately affecting organs that border the bladder (prostate, uterus, etc.) or other organs such as the lung, bone, and liver. Intravesical therapy and surgery may be considered. If invasion of the muscle is seen on the biopsy, the tumor is at least stage T2, in which case more aggressive treatments (surgery, radiation, and/or chemotherapy) are typically considerations.
There are many lymph nodes that also surround the bladder. Lymph nodes are small glands that store the white blood cells that help to fight disease throughout the body. Cancer cells from invasive bladder tumors may appear in the lymph nodes. Although they can often only be seen with a microscope, they may be seen on scans as enlarged lymph nodes – cancer cells in the lymph nodes indicate that the tumor has spread and will influence the management of the bladder cancer patient. Chemotherapy may be suggested.
Generally, after the diagnosis of a bladder tumor, the urologist will suggest that the patient have an outpatient procedure in the hospital to examine the bladder more completely under anesthesia (general or spinal) and to remove, if possible, those tumors which are suitable for resection. The doctor may refer to this procedure as a TURBT (transurethral resection of a bladder tumor).
The TURBT is “incision-less” surgery usually performed as an outpatient procedure. It is the first-line surgical treatment for bladder tumors. Like the cystoscope, the resectoscope, the instrument used to remove the tumor in the TURBT, is introduced through the urethra into the bladder. Attached to this scope is a small, electrified loop of wire which is moved back and forth through the tumor to cut and remove the tissue. Newer technology known as “blue light” cystoscopy uses an optical imaging agent is often used during this procedure at major medical centers.
Electricity is also used to seal off bleeding vessels. This is sometimes called electrocauterization or fulguration. One of the advantages of this procedure is that it can be performed repeatedly with minimal risk to the patient and with excellent results. There is less than a 10% risk of infection or injury to the bladder, and both are easily correctable.
The most common risks of the TURBT are bleeding, pain, and burning when urinating and all three are temporary. If the bladder tumor is large, the urologist may choose to leave a catheter in the patient’s bladder for a day or two to minimize problems occurring from bleeding, clot formation in the bladder or expansion of the bladder due to possible storage of excess urine or blood. Even if the tumor is small, a catheter may be inserted to rinse the bladder out if the bleeding persists.
All the specimens from the TURBT will be sent to the pathologist for review. The pathologist will confirm the type of bladder cancer and the depth of invasion into the bladder wall, if any. These findings, along with results from imaging such as CT scans, will determine if further treatment is necessary.
Check out our Patient Tipsheet on the TURBT (PDF), filled with advice from patients who have experienced it.
Certain types of bladder tumors are hard to remove using surgical procedures like a TURBT, particularly flat tumors (carcinoma in situ). In addition, some tumors may be likely to recur after initial resection. In these cases, special medications that destroy cancer cells may be placed directly into the bladder. This treatment is called intravesical therapy.
There are two principal drugs that are used as intravesical chemotherapy or immunotherapy.
- Bacille Calmette-Guerin or BCG is intravesical immunotherapy which causes an immune or allergic reaction that has been shown to kill cancer cells on the lining of the bladder. BCG is often preferred for patients who have high-grade tumors or who have CIS or T1 disease.The urologist may also suggest maintenance therapy using BCG. The rationale for maintenance therapy is that the initial therapy plus intermittent therapy for 2 to 3 years may provide a decreased likelihood that the tumors will recur. The disadvantage to maintenance therapy is prolonged bladder irritation, fever, and bleeding which may force the doctor to decrease the BCG dosage or to discontinue the therapy. Both Mitomycin C and BCG are administered through a catheter which is placed in the bladder through the urethra. The drug is then introduced into the bladder.
- Mitomycin C is an intravesical, anti-cancer drug that has been shown to be effective after the TURBT in reducing the number of recurrences of bladder tumors by as much as 50%. An advantage of Mitomycin C is that it is not easily absorbed through the lining of the bladder and into the blood and, thus, less risky than chemotherapy given intravenously. Side effects from the drug can be pain when urinating and/or “chemical cystitis”, an irritation of the lining of the bladder which can feel like a urinary tract infection. Both these side effects are temporary and will disappear when the therapy is stopped. This drug may be delivered into the bladder immediately after TURBT. For more information, see the video above about TURBT and intravesical chemotherapy.
Check out our Patient Tipsheet on BCG (PDF), filled with advice from patients who have experienced it.
If a bladder tumor invades the muscle wall or if CIS or a T1 tumor still persists after BCG therapy, the urologist may suggest removal of the bladder or a radical cystectomy. Before any radical surgery is performed, a series of CT scans or an MRI will be ordered to exclude the possibility of metastatic or “distant” disease in other parts of the body. If the patient has metastatic disease, surgery to remove the bladder is not recommended and patients will be referred to a medical oncologist to discuss chemotherapy. The two types of surgery performed for muscle-invasive bladder cancer are partial or complete radical cystectomy.
Partial cystectomy is fairly uncommon and is only performed:
- if the muscle-invasive bladder tumor is the first and only bladder tumor the patient has had and
- if the tumor is in a location where it is easily accessible for surgery and, if removed, will leave the bladder with enough capacity for the patient to have normal bladder function.
A complete radical cystectomy requires complete bladder removal, and in men, almost always involves removal of the prostate as well. For women, in addition to removing the bladder, the surgeon may also remove the uterus, fallopian tubes, ovaries and cervix, and occasionally a portion of the vaginal wall. In addition, the surgeon will remove lymph nodes surrounding the bladder, and perhaps even more, to determine whether the cancer has progressed to the lymph nodes, which then could result in metastasis. The lymph node removal is an important method of accurately staging the progression of the disease. Cystectomy can be performed through an open incision or laproscopically, typically with robotic assistance. Removal of the bladder also requires the surgeon to create a passage for the urine to go from the kidney to outside the body. Even though the bladder is removed, the kidneys, ureters and urethra are still in place. Because no artificial bladder has yet been invented that is tolerated by the urinary tract system, the urologist has learned to create the passageway or conduit between the kidneys and ureters and the urethra using a piece of the patient’s own intestine.
Check out our Patient Tipsheet on Radical Cystectomy (PDF), filled with advice from patients who have experienced it.
- An ileal conduit is the easiest and most common reconstruction performed by the urologist. A small portion of the ileum or small intestine is disconnected. One side of the piece of ileum is attached to a skin opening on the right side of the abdomen and a small stoma or mouth is created. A plastic appliance or ostomy bag is placed over the stoma to collect the urine. The ureters are sewn or re-implanted near the other end of the ileum. Because the nerves and the blood supply are preserved, the conduit is able to propel the urine into the appliance. Read some practical questions & answers from Nancy, a bladder cancer survivor with an Ileal Conduit and check out our Patient Tipsheet on the Ileal Conduit (PDF), filled with advice from patients who have it.
- A continent cutaneous pouch (CCP) is an internal storage “container” for urine. Using a combination of small and large intestine, the urologist reconstructs the tubular shape of the intestine and creates a sphere or pouch. This pouch is connected to the skin on the abdomen by a small stoma creating a type of continent urinary reservoir; no external bag 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, in some cases, covering the stoma with a bandage. Read some practical questions & answers from Karen, a bladder cancer survivor living with a CCP, and check out our Patient Tipsheet on the Indiana Pouch (PDF), filled with advice from patients who have it.
- A neobladder is also a type of internal reservoir for storing urine. Using a portion of small intestine, the urologist reconstructs the tubular shape of the intestine and creates a sphere. The surgeon then connects the pouch to the urethra, creating a neobladder, in which case the patient can void (pass urine out of the body) normally. By tensing the abdominal muscles and relaxing certain pelvic muscles, the patient is able to push the urine through the urethra. Read some practical questions and answers from Michael, a bladder cancer survivor living with a neobladder, and check out our Patient Tipsheet on the Neobladder (PDF), filled with advice from patients who have it.
A radical cystectomy is considered major surgery and at least 20% of patients have complications as a result, regardless of approach. The choice of which type of reconstruction to utilize is a highly-individualized decision between the patient and the doctor, and depends on a variety of factors, including the patient’s overall health, age, and extent of disease. There are advantages and disadvantages to each type of reconstruction.
Chemotherapy refers to drugs used to treat cancer systemically. These drugs are administered by injection directly into the patient’s veins, and circulate through the bloodstream to attack cancer cells anywhere in the body. Chemotherapy is typically used to treat bladder cancer that has metastasized, which means the cancer cells have spread beyond the bladder to other organs.
Neoadjuvant chemotherapy is the term used for chemotherapy prior to surgery. An important clinical trial has 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 and 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. The two regimens recommended for neoadjuvant treatment are either Dose Dense MVAC or GC (discussed below).
Adjuvant chemotherapy is the term used for chemotherapy following surgery. Typically, removal of the bladder also involves removal of a number of lymph nodes surrounding the bladder, which are then sent to the pathology lab for analysis. If the pathology results indicate that the cancer has spread to the lymph nodes, the doctor may recommend chemotherapy to help prevent any cancer recurrence. Dose Dense MVAC or GC are typically recommended in this setting.
If bladder cancer is found to have spread to other sites, 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, achieving shrinkage of tumor, relieving symptoms, and extending life as long as possible.
Cisplatin based chemotherapy has been the standard treatment for bladder cancer for many years, based on the results of clinical trials from the 1990s. The two regimens most commonly used are dose-dencse (DD) MVAC and GC. MVAC uses four drugs: methotrexate (MTX, Amethopterin, Rheumatrex, Trexall), vinblastine (Velban), doxorubicin (Adriamycin, Rubex), and cisplatin (Platinol). The advent of effective anti-nausea medication and injections that can keep immune systems from being depleted by chemotherapy have improved our ability to give MVAC safely on an accelerated dose dense schedule. The 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. 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 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.
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 cancers are chemosensitive and therefore 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) a “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.
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