Types of Treatment for Bladder Cancer

Your doctor may discuss more than one treatment option with you, depending on the type of bladder cancer you have and its stage. You may feel that you need to make a decision quickly. But give yourself time to absorb the information you have learned. You will want to weigh the benefits of each treatment against its possible side effects and risks. Other factors to consider include your general health, age, and personal preferences.

You may want to get a second opinion. This can provide more information and help you feel more confident about the treatment plan you choose. Your doctor should not mind your doing this. In fact, some insurance companies require you to get a second opinion. If your first doctor has done tests, the results can often be sent to the second doctor so that you will not have to have them done again. If you are in an HMO (health maintenance organization), find out its policy on second opinions.

The treatment options for bladder cancer range from simple cystoscopy with removal of the tumor to complete bladder removal and reconstruction of an artificial bladder. Depending on the stage and type of bladder cancer, there may be no further surgery, chemotherapy, radiation therapy, or intravesical therapy (treatment given directly to the bladder through the urethra). Sometimes the treatments are given when the disease is first diagnosed. Other times, your doctor may suggest starting with simpler treatments and reserve more complicated surgery, such as removing the bladder, for a later date, if needed.

Surgery

The type of surgery done for bladder cancer will depend on its stage.

Transurethral surgery: For early stage or superficial bladder cancers, a transurethral resection of bladder tumor (TURBT) is most common. This means that the tumor is removed by inserting a cystoscope into the bladder through the urethra. An instrument called a resectoscope that uses electrical current to remove the cancer. Local anesthesia (numbing the area) or general anesthesia (“putting the patient to sleep”) is used. In this procedure there is no need to cut into the abdomen. After surgery, more steps may be taken to ensure that the tumor has been destroyed. Any remaining cancer may be treated using the cystoscope and burning the base of the tumor (fulguration). Cancer can also be destroyed using the cystoscope and a high-energy laser.

After transurethral surgery, you can usually return home the same day or the next day and can resume your usual activities in less than 1 to 2 weeks.

The side effects of transurethral bladder surgery are generally mild and do not usually last long. There may be some bleeding and discomfort right after surgery.

Cystectomy: For invasive bladder cancer, it is usually necessary to remove the diseased area by cutting through the bladder wall. For this surgery, a cut (incision) is made through the abdomen. In rare cases, if the cancer is not very large, it may be possible to remove it and only a part of the bladder. This operation is called a partial cystectomy.

If the cancer is larger or if more than one area of cancer is present, a radical cystectomy is done. This operation removes the entire bladder and nearby lymph nodes. In men, the prostate is also removed. In women, the uterus (womb), ovaries, a small portion of the vagina, and fallopian tubes (tubes that connect the ovaries and uterus) are often removed with the bladder.

For a partial or radical cystectomy, general anesthesia is used. You will need to stay in the hospital for about 7 to 10 days. You can usually go back to your usual activities in about 4 to 6 weeks.

The side effects of radical cystectomy (removing the bladder and nearby organs) are more serious than for a TURBT. There is a risk of excessive bleeding, urinary tract infections, urine leakage, and blockage of urine flow. Without a bladder to store urine, you will need to have a urostomy (discussed below) or some other form of reconstructive surgery.

Reconstructive surgery: If your whole bladder is removed, you will need another way to store and remove urine. Several types of reconstructive surgery can be done, depending on your medical situation and personal preferences. Removing the bladder and creating another system for draining urine can require major emotional and physical adjustment. You should feel free to discuss your feelings and concerns with your health care team.

One option is a urostomy. In this procedure, a short piece of the small intestine (small bowel) or part of the large intestine (colon) is separated from the rest of the intestine and attached to the ureters. Urine from the ureters flows into this small sac, which is connected to the skin of the abdomen. Some urostomies empty continuously into a small bag placed over the connection and are worn under clothing.

Another option is a continent diversion. Here, urine is stored in the intestinal sac and emptied only by placing a drainage tube (catheter) into the hole. Some patients prefer this because there is no bag on the outside. Newer methods of reconstructive surgery can route the urine back into the urethra, restoring close to normal urination. Sometimes a diversion is made without removing the bladder. This may be done to relieve blockage of urine flow in a patient whose cancer may have spread or could not be removed by surgery.

The possible side effects of urostomy and urinary diversion include wound infections, urine leaks, pouch stones, and blockage of urine flow.

The United Ostomy Association (UOA) conducts programs to help patients who have had urostomy surgery. There are also enterostomal therapists in the community (specialists in the field) who can be helpful. The UOA can provide referrals to these therapists. Call the American Cancer Society for information about these and other services in your area.

Intravesical Immunotherapy

Intravesical therapy means that a treatment is placed directly into the bladder through a catheter rather than being given by mouth or injected into a vein. The most common form of intravesical therapy used in bladder cancer is immunotherapy. This treatment causes the body’s own natural defenses (immune system) to attack the bladder cancer.

Bacillus Calmette-Guérin (BCG) (BCG) is considered the most effective intravesical immunotherapy for treating low-stage bladder cancer. BCG, a bacterium that is sometimes used to vaccinate people against tuberculosis, is given directly into the bladder through a catheter. The body’s immune system responds to BCG. Immune system cells are attracted to the bladder and activated by BCG, which in turn affects the bladder cancer cells. It is usually given once a week for 6 weeks. Sometimes long-term“maintenance” BCG therapy is given.

Treatment with BCG may cause flu-like symptoms (mild fever, chills, and fatigue), as well as a burning sensation in the bladder. A persistent fever (greater than 100.5°F) that does not respond to an analgesic (such as aspirin or Tylenol) may indicate life-threatening spread of BCG infection throughout the body. In such cases, prompt medical care should be sought. Usually these infections respond to an antibiotic drug used for treating tuberculosis called isoniazid (INH).

Chemotherapy

Chemotherapy is the use of medicines to destroy cancer cells. Anticancer drugs specifically attack rapidly dividing cells. While cancer cells are rapidly dividing cells, there are some normal cells in the body that also divide rapidly. The effect chemotherapy has on normal cells depends on which medicine is used, how much is given, how the medicine is introduced into the body, as well as the individual patient. Chemotherapy used to treat bladder cancer can be either intravesical or systemic (by mouth or injection and affecting cells throughout the body).

Chemotherapy may be used to shrink a large tumor so that it can be removed by surgery or a less extensive operation. When given as treatment before surgery, this is known as neoadjuvant therapy . Chemotherapy can be given after surgery or radiation (as adjuvant therapy ) to prevent the growth of stray cancer cells remaining in the body. In most cases, these stray cancer cells cannot be recognized by routine tests such as x-rays but are assumed to be present.

Intravesical chemotherapy: In intravesical chemotherapy, a urinary catheter is used to place the anticancer drugs directly into the bladder. These medicines reach cancer cells near the bladder lining but do not reach cancer cells that are in the kidneys, ureters, and urethra; cancer cells that may have invaded deeply into the bladder wall; or cancer cells that have spread to other organs.

For this reason, intravesical chemotherapy is used only for noninvasive (stage 0) or least invasive (stage I) bladder cancers. This treatment uses drugs that kill actively growing cancer cells. Many of the same drugs are given by systemic chemotherapy (by mouth or into a vein) to treat more advanced stages of bladder cancer. Mitomycin is the drug used most often for intravesical chemotherapy. Other drugs are doxorubicin (Adriamycin), epirubicin, valrubicin, and thiotepa. One of the main advantages of intravesical chemotherapy is that the drugs do not usually spread throughout the body. This limits the unwanted side effects that can occur with systemic chemotherapy from affecting other organs.

The main side effect of intravesical chemotherapy is irritation and a burning feeling in the bladder. Thiotepa, which is used less often, has been absorbed from the bladder at times and caused toxic effects in the rest of the body.

Systemic chemotherapy: Systemic chemotherapy uses anticancer drugs that are injected into a vein or given by mouth. These medicines travel through the bloodstream to all parts of the body. In contrast to intravesical chemotherapy, systemic chemotherapy can attack cancer cells that have already spread beyond the bladder to lymph nodes and other organs.

A combination of chemotherapy drugs is more effective than any single drug in treating bladder cancer. Chemotherapy combinations are often abbreviated by the first letter of each of the drugs. The combinations used most often for bladder cancer are:

• M-VAC (methotrexate, vinblastine, doxorubicin [Adriamycin], and cisplatin)
• MCV (methotrexate, cisplatin, and vinblastine).

Other drugs sometimes used in systemic chemotherapy of bladder cancer include cyclophosphamide, gemcitabine, and paclitaxel.

For other types of cancer that occur less often in the bladder, such as squamous cell carcinoma and adenocarcinoma, treatment with chemotherapy usually uses drugs that work on the same types of tumors elsewhere in the body.

Because many patients with bladder cancer are over the age of 65 and have other serious medical conditions, chemotherapy can be difficult. Many older patients, however, can tolerate chemotherapy well. Factors that help predict whether or not a person will respond to chemotherapy include the patient’s performance status (ability to function normally and perform activities of daily living), whether the cancer has spread to other organs (such as the liver, lung, or bone), and whether certain blood test levels are elevated.

Chemotherapy drugs kill cancer cells but can also damage some normal cells, leading to side effects. The side effects of chemotherapy depend on the type of drugs, the amount taken, and the length of treatment. Temporary side effects might include nausea and vomiting, loss of appetite, loss of hair, and mouth sores. Because chemotherapy can damage the blood-producing cells of the bone marrow, patients may have low blood cell counts. This can result in:

• infection (due to low white blood cells)
• bleeding or bruising after minor cuts or injuries (due to low blood platelets)
• fatigue (due to low red blood cell counts)

Most side effects disappear once treatment is stopped. There are remedies for many of the temporary side effects of chemotherapy. For example, drugs called antiemetics can be given to prevent or reduce nausea and vomiting. Drugs called growth factors can help bone marrow recover after chemotherapy and can treat problems resulting from low blood counts. Some growth factors increase production of white blood cells by the bone marrow. These drugs are sometimes used to prevent infections in patients on chemotherapy. Anemia (too few red blood cells) may be treated with blood cell transfusions or with erythropoietin, a growth factor that increases production of red blood cells.

If you have side effects, talk with your doctor or nurse because they often know ways to help. You should also ask about NCCN’s specific guidelines for treating many of the problems that occur with chemotherapy, such as nausea and vomiting, fatigue, and low white blood cell counts (neutropenia).

Radiation Therapy

Radiation therapy uses high-energy radiation to kill cancer cells.

• External beam radiation therapy focuses radiation from outside of the body on the cancer.
• Internal radiation therapy (brachytherapy) uses a small radioactive pellet that is placed directly into the cancer. This treatment is also called interstitial radiation therapy.

After surgery, radiation can kill small deposits of cancer cells that may not be visible during surgery. The combination of radiation therapy and chemotherapy given after transurethral bladder surgery can sometimes completely destroy cancers that would otherwise require cystectomy for complete removal. Thus, a bladder-sparing approach helps avoid the substantial physical and emotional consequences of bladder removal.

If a tumor is positioned so that surgery is difficult, radiation may be used before surgery to shrink the tumor, making surgery easier. Radiation also might be used to ease (palliate) the symptoms of advanced cancer, such as urine blockage, bleeding, and pain.

Mild skin irritation, nausea, bladder irritation, diarrhea, or fatigue may occur after radiation therapy. These symptoms are usually temporary. If you have these or other side effects from radiation therapy, you should discuss them with your health care team. They can suggest ways to lessen many of these discomforts.

Palliative and Supportive Care

Most of this document discusses ways to successfully treat some people with bladder cancer and to help others live longer by removing or destroying bladder cancer cells. But maintaining your quality of life is another important goal. Don’t hesitate to discuss your symptoms or how you feel with your cancer care team. There are effective and safe ways to treat other symptoms of bladder cancer, including pain and most of the side effects caused by bladder cancer treatments.

Palliative treatments are intended to reduce or prevent symptoms but are not expected to cure the cancer. Palliative care may include radiation or chemotherapy treatments that relieve symptoms by shrinking the tumor.

Supportive care is similar to but not exactly the same as palliative care. Supportive care uses measures to relieve symptoms during cancer treatment and improve quality of life, but it is not expected to destroy the cancer. Pain medicine is an example of supportive care.

Pain is a significant concern for patients with bladder cancer. Growth of the cancer around certain nerves may cause severe pain. It is important that patients tell their doctors if they have pain. Otherwise the doctors can’t help. For most patients, treatment with morphine or other medicines related to opium (called opioids) will reduce the pain considerably. For more information on the treatment of cancer pain, please refer to the Cancer Pain Treatment Guidelines for Patients or contact the ACS or NCCN to request a printed copy.

Complementary and Alternative Therapies

If you are considering any unproven alternative or complementary treatments, it is best to discuss this openly with your cancer care team and request information from the ACS or the National Cancer Institute. Some unproven treatments can interfere with standard medical treatments or may cause serious side effects.

Other Things to Consider During and After Treatment

During and after your treatment for bladder cancer you may be able to speed up your recovery and improve your quality of life by taking an active role. Learn about the benefits and risks of each of your treatment options and ask questions of your cancer care team if there is anything you do not understand. Learn about and look out for side effects of treatment and report these promptly to your cancer care team so that they can take steps to ease them and shorten their duration.

Remember that your body is as unique as your personality and your fingerprints. Although understanding your cancer’s stage and learning about your treatment options can help predict what health problems you may face, no one can say for sure how you will respond to cancer or its treatment.

You may have special strengths such as a history of excellent nutrition and physical activity, a strong family support system, or a deep faith, and these strengths may make a difference in how you respond to cancer. There are also experienced professionals in mental health services, social work services, and pastoral services who may help you in coping with your illness.

You can also help in your own recovery from cancer by making healthy lifestyle choices. If you use tobacco, stop now. Quitting will improve your overall health, and the full return of your sense of smell may help you enjoy a healthy diet during recovery. If you use alcohol, limit how much you drink. Have no more than 1 or 2 drinks per day. Good nutrition can help you get better after treatment. Eat a nutritious and balanced diet, with plenty of fruits, vegetables, and whole grain foods. Ask your cancer care team if you may benefit from a special diet — they may have specific suggestions for people who have had radiation therapy or chemotherapy.

If you are being treated for cancer, be aware of the battle that is going on in your body. Radiation therapy and chemotherapy add to the fatigue caused by the disease itself. To help with the fatigue, plan your activities around when you have more energy. Be sure to plan time for rest periods during the day but don’t let them interfere with your sleep at night. Some people find that some type of regular physical activity helps them to feel better and restore their energy. Ask your cancer care team whether your cancer or its treatments might limit your exercise program or other activities.

A cancer diagnosis and its treatment is a major life challenge, with an impact on you and everyone who cares for you. Before you get to the point where you feel overwhelmed, consider attending a meeting of a local support group. If you need assistance in other ways, contact your hospital’s social service department or the American Cancer Society for help in contacting counselors or other services.

About Clinical Trials

Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions:

• Is the treatment helpful?
• How does this new type of treatment work?
• Does it work better than other treatments already available?
• What side effects does the treatment cause?
• Are the side effects greater or less than the standard treatment?
• Do the benefits outweigh the side effects?
• In which patients is the treatment most likely to be helpful?

Types of clinical trials: A treatment is studied in 3 phases before it is eligible for approval by the U.S. Food and Drug Administration (FDA).

Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment and how much of it can be given safely. The treatment has been well tested in laboratory and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug.

Phase II clinical trials: These studies are designed to see if the drug works. Patients are given the highest dose that doesn’t cause severe side effects (determined from the phase I study) and closely observed for an effect on the cancer. The doctors also look for side effects.

Phase III clinical trials: Phase III studies involve large numbers of patients. Some clinical trials may enroll thousands of patients. One group (the control group) receives the standard (most accepted) treatment. The other groups receive the new treatment. All patients in phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had much better result than the others.

If you are participating in a clinical trial, you will have a team of experts taking care of you and monitoring your progress very carefully. The study is especially designed to pay close attention to you. However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to discover. Although most side effects disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial.

Deciding to enter a clinical trial: Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study in detail to you and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study will not prevent you from getting other medical care you may need.

To find out more about clinical trials, talk to your cancer care team. Among the questions you should ask are:

• Is there a clinical trial for which I would be eligible?
• What is the purpose of the study?
• What kinds of tests and treatments does the study involve?
• What does this treatment do?
• What is likely to happen in my case with, or without, this new research treatment?
• What are my other choices and their advantages and disadvantages?
• Will I know which treatment I receive?
• How could the study affect my daily life?
• What side effects can I expect from the study? Can the side effects be controlled?
• Will I have to be hospitalized? If so, how often and for how long?
• Will the study cost me anything? Will any of the treatment be free?
• If I am harmed as a result of the research, what treatment would I be entitled to?
• What type of long-term follow-up care is part of the study?
• Has the treatment been used to treat other types of cancers?

The American Cancer Society offers a clinical trials matching service for patients, their family, and friends. You can find this service on our Web site (www.cancer.org) or through our national call center at 1-800-ACS-2345. Based on the information you provide about your cancer type, stage, and previous treatments, this service will compile a list of clinical trials that match your medical needs. In finding a center most convenient for you, the service can also take into account where you live and whether you are willing to travel.

You can also get a list of current clinical trials by calling the National Cancer Institute’s (NCI) Cancer Information Service toll free at 1-800-4-CANCER or by visiting the NCI clinical trials Web site at www.cancer.gov/clinical_trials.

STAGES OF BLADDER CANCER

For more information on these treatment guidelines, or on cancer in general, call the NCCN at 1-888-909-NCCN or the American Cancer Society at 1-800-ACS-2345. Or you can visit these organizations’ web sites at www.cancer.org (ACS) and www.nccn.org (NCCN).

© 2005 by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS). All rights reserved. The information herein may not be reproduced in any form for commercial purposes or downloaded and stored in any information-retrieval system without the express written permission of the NCCN and the ACS. Single copies of each page may be printed out for personal, noncommercial use only.