Bladder Cancer Treatment
The choice of an appropriate treatment is based on the stage of
the tumor, the severity of the symptoms, and the presence of other medical conditions.
Generally, superficial tumors (stages 0 and I) are treated by removing the lesion (without
removal of the rest of the bladder) and by sometimes administering local (directly into
the bladder) chemotherapy. However,
because the risk of recurrence is so high (70 -100%), people with bladder cancer require
constant follow-up for the rest of their lives.
The treatment for stage II bladder tumors may involve removal of the tumor and a trial of
BCG immunotherapy (see below) with serial follow-up. However, most people with stage II
and those with stage III tumors will require bladder removal (radical cystectomy). In some
patients with stage III tumors who opt not to have surgery or who cannot tolerate surgery,
a combination of chemotherapy and radiation may be appropriate. Most patients with stage
IV tumors cannot be cured and surgery is not indicated. In these patients, chemotherapy is
often considered.
Medications used in Bladder Cancer Treatment
Chemotherapy for the treatment of bladder cancer can be administered through the vein
or into the bladder. Chemotherapy is usually given by vein to treat patients with stage IV
bladder cancer. Alternatively, chemotherapy may also be given to patients with stage II
and stage III cancer after surgery in an attempt to prevent recurrence of the tumor.
Chemotherapy may be given as a single agent or in different combinations. These include:
The combination of two of these drugs, gemcitabine and cisplatin, have recently been
shown to be as effective and with less side effects as an older regimen known as MVAC
(methotrexate, vinblastine, doxorubicin and cisplatin) and in many centers has replaced
MVAC. The combination of paclitaxel and carboplatin has also been effective and is
frequently used.
Intravesical chemotherapy for bladder cancer treatment
A Foley catheter can be used to
instill the medication directly into the bladder (intravesical chemotherapy) in patients
with stage I disease. The catheter is removed immediately after the medication has been
instilled, though you are instructed to try to hold the medication in your bladder for at
least two hours after treatment. Additionally, you may be asked to rotate from side to
side every 15 - 30 minutes to ensure complete exposure of the entire bladder wall to the
medication.
Several different types of medications may be used for intravesical chemotherapy, such
as:
- Thiotepa
- Mitomycin-C
- Doxorubicin (Adriamycin)
Common side effects include bladder wall irritation and pain when urinating. Choice of
a specific agent is usually based on the stage of the tumor.
Immunotherapy as a bladder cancer treatment
Additionally, bladder cancers are often treated by what is known as intravesical immunotherapy, in which a medication is
given that causes your own immune system to attack and kill the tumor cells. Immunotherapy
is usually performed using Bacille Calmette-Guerin (commonly known as BCG), which is a
solution of genetically altered tubercular bacteria that has been rendered avirulent (not
able to produce infection). This medication is administered through a Foley catheter to
instill the medication directly into the bladder. Since BCG is a biological agent, special
precautions must be taken.
Potential side effects, which include bladder irritability, urinary frequency, urinary
urgency, and painful urination are reported by 90% of the people treated with BCG.
However, the symptoms usually resolve within a few days after treatment. Other rare side
effects include hematuria (blood in the
urine), malaise, nausea, chills, joint pain,
and itching. Rarely, a systemic tubercular (TB) infection can develop if the TB used does
not remain avirulent, requiring treatment with anti-tuberculosis medication. Systemic
infection is suspected if you develop an elevated temperature that lasts for more than one
day.
Surgery as a Bladder Cancer Treatment
TRANSURETHRAL RESECTION OF THE BLADDER (TURB):
People with stage 0 or I bladder cancer are usually treated with transurethral
resection of the bladder (TURB). This procedure is performed under general or spinal
anesthesia. A cutting instrument is then inserted through the urethra to remove the
bladder tumor.
BLADDER REMOVAL:
Most people with stage II or III bladder cancer will opt for bladder removal (radical
cystectomy). Partial bladder removal may be performed if there is only a single lesion
with no signs of metastasis. However, only about 10% of the people with bladder cancer
meet this criterion.
Radical cystectomy in men usually involves removal of the bladder, prostate, and seminal vesicles. In women, the urethra, uterus, and the
anterior (front) vaginal wall are removed along with the bladder. Often, the pelvic lymph
nodes are also removed during the surgery for pathological examination. About half of the
people treated with radical cystectomy will be completely cured; the other half shows
signs of metastasis at the time of the surgery.
A urinary diversion surgery (a surgical procedure to create an alternate method for urine
storage) is usually performed with the radical cystectomy procedure. Two common types of
urinary diversion are an ileal conduit and a continent urinary reservoir.
ILEAL CONDUIT:
- An ileal conduit is a small urine reservoir that is surgically created from a small
segment of bowel. The ureters that drain urine from the kidneys are attached to one end of
the bowel segment and the other end is brought out through an opening in the skin to
create a stoma. The stoma allows the patient to drain the collected urine out of the
reservoir.
- People who have had an ileal conduit will need to wear an external urine collection
appliance at all times. Possible complications associated with ileal conduit surgery
include: bowel obstruction, blood clots, urinary tract infection, pneumonia, skin
breakdown around the stoma (the opening in the skin connecting to the ileal conduit), and
long-term damage to the upper urinary tract.
CONTINENT URINARY RESERVOIR:
- A continent urinary reservoir is another method of creating a urinary diversion. In this
method, a segment of colon is removed and used to create an internal pouch to store urine.
This segment of bowel is specially prepared to prevent reflux of urine back up into the
ureters and kidneys, and also to reduce the risk of involuntary loss of urine. Patients
are able to insert a catheter periodically to drain the urine. A small stoma is placed
flush to the skin. Possible complications include: bowel obstruction, blood clots,
pneumonia, urinary tract infection, skin breakdown around the stoma, ureteral reflux, and ureteral
obstruction.
Bladder
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