Bladder Cancer Treatment

This information is an interpretation of various studies that have been published in medical journals. The information below represents various views of nurses and doctors who serve on the American Cancer Society’s Cancer Information Database Editorial Board. Keep in mind that the information provided in this article is not designed to be taken as medical advice or to replace the opinion and judgment of your personal cancer care team. It is simply designed to help you make informed decisions together with your doctor. The general treatment options that will be discussed may not be what your doctor recommends, and there may be various reasons why. You should take the time to find out what specific treatments doctors recommend for you.

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Surgery for Bladder Cancer

Bladder cancer surgery involves removing part or all of the bladder, depending on severity of the cancer, and reconstructing pathways for waste disposal. The ideal scenario is the removal of as little tissue as possible. 

Transurethral Resection of Bladder Tumor (TURBT)

Transurethral resection of bladder tumor (TURBT) is a procedure often used to diagnose bladder cancer and determine if it has invaded the bladder wall muscle. TURBT is also the most common treatment for early-stage superficial cancers. The goal is to remove cancerous cells and tissues down to the bladder wall muscle layer.

During TURBT, the doctor inserts a thin, rigid cystoscope called a resectoscope through the urethra into the bladder. This allows the surgery to be done without abdominal incisions. The wire loop on the end of the resectoscope removes abnormal tissues or tumors, which are sent for testing. Additional steps like burning tissue or using a laser may ensure all cancer is destroyed.

Possible side effects of TURBT are generally mild, like bleeding and painful urination after surgery. Patients can usually go home the same or the next day and resume normal activities within 1-2 weeks. However, bladder cancer often recurs and may require repeated TURBTs. This can scar the bladder, leading to side effects like frequent urination or incontinence. For some patients with recurring non-invasive tumors, the doctor may just burn small tumors found during exams rather than removing them.

Cystectomy

Cystectomy involves a partial or complete removal of the bladder. This is done when the cancer is severe.

Partial cystectomy

If the cancer has invaded the bladder muscle layer but is small and localized, it may be removed along with part of the bladder wall without total bladder removal. The bladder wall is then stitched closed and nearby lymph nodes are removed to check for cancer spread. This surgery allows bladder preservation but may reduce bladder capacity, requiring more frequent urination; the main drawback is bladder cancer may still recur in the remaining bladder wall.

Radical Cystectomy

If the cancer is larger or in multiple areas of the bladder, a radical cystectomy will be needed to remove the entire bladder and nearby lymph nodes. In men, the prostate and seminal vesicles are also removed, while in women the ovaries, fallopian tubes, uterus, cervix, and part of the vagina are removed. Cystectomy is usually done through an incision in the abdomen, requiring a week-long hospital stay and several weeks of recovery before normal activities can be resumed.

In some cases, laparoscopic or robotic surgery may be used, which involves small incisions and specialized instruments controlled by the surgeon. This type of surgery may result in less pain and quicker recovery, but its long-term efficacy is still being studied. Regardless of technique, the surgery must be done by an experienced bladder cancer surgeon to minimize recurrence risk.

Reconstructive Surgery After Cystectomy

Removing the bladder leaves you with no place to store urine. Several reconstructive surgeries are done to address this:

Incontinent diversion

An incontinent diversion involves removing a piece of the intestine to create an ileal conduit for urine drainage. The ureters are connected to the conduit, with the other end connected to a stoma opening on the abdomen. A bag on the skin around the stoma collects the continuously draining urine. This allows urine drainage but no control over flow.

Continent diversion

A continent diversion also uses the intestine to create a pouch for urine that connects to the stoma. However, a valve at the stoma allows urine storage in the pouch, which is emptied several times a day via a catheter. Some prefer this method since there is no external bag.

Neobladder

For a neobladder, a pouch created from the intestine is connected to the ureters and urethra, allowing normal urination on a schedule. Over time, most regain daytime control but nighttime incontinence may occur. If cancer cannot be removed, a diversion may be made without bladder removal to relieve urine blockage.

Cystectomy side effects

The surgery in itself involves the following risks:

  • Reactions to anesthesia
  • Bleeding
  • Blood clots in the legs or lungs
  • Damage to nearby organs
  • Infection

Removing parts or the entirety of the bladder during a cystectomy can lead to the following:

  • Infections
  • Urine leaks
  • Incontinence
  • Pouch stones
  • Blockage of urine flow
  • Absorption problems (depends on the amount of intestine that was used)
  • Inability to have erections in men
  • Inability to produce semen
  • Discomfort or loss of feeling during sex for women

Intravesical therapy for bladder cancer

Intravesical therapy involves placing medicine directly into the bladder through a catheter instead of using the IVS route or ingesting oral pills. It is primarily used for early-stage bladder cancer when the cancer is still in the lining and hasn't penetrated deeply into the bladder wall. It is usually given after a TURBT. For higher-stage cancers, it is not used as a primary treatment, because it has reduced efficacy. It may still be given weekly or less often for up to 3 years.

Intravesical immunotherapy

Immunotherapy helps strengthen the immune system and allows it to fight cancer more vigorously.

Bacillus Calmette-Guerin (BCG)

Bacillus Calmette-Guerin (BCG) is the most common immunotherapy for early bladder cancer. It is a germ related to tuberculosis that stimulates the immune system when put in the bladder via a catheter. Side effects include flu-like symptoms for 2-3 days after treatment, burning with urination, increased urination, and blood in urine. BCG can rarely cause serious infections, so it is not used in people with weakened immune systems.

Nadofaragene firadenovec (Adstiladrin)

Nadofaragene firadenovec (Adstiladrin) is a gene therapy that delivers the interferon alfa-2b gene into bladder cells using a virus vector. The cells then produce extra immune protein to attack cancer cells. It can treat high-risk non-muscle invasive bladder cancers unresponsive to BCG. Side effects may include fatigue, bladder spasms, frequent urination, and blood in urine. The virus rarely causes infections in people with normal immunity.

Intravesical Chemotherapy

Intravesical chemotherapy involves inserting chemotherapy drugs directly into the bladder through a catheter to kill actively growing cancer cells. Mitomycin and gemcitabine are commonly used; heating the chemo solution before administration may improve effectiveness. Valrubicin is another option in some cases. The main side effects are bladder irritation, burning sensation, and blood in urine. A major advantage over systemic chemo is that the drugs usually remain localized, avoiding widespread side effects.

Delivering chemo drugs into the bladder is most often used when intravesical immunotherapy is ineffective. The drugs can also be given systemically to treat more advanced bladder cancers. Hyperthermic intravesical therapy is when the chemo solution is heated before being put into the bladder, which may help the drug penetrate cancer cells. Electromotive mitomycin therapy, where mitomycin is heated inside the bladder, may be more effective than standard intravesical mitomycin administration.

Chemotherapy for Bladder Cancer

Chemotherapy (chemo) uses drugs to treat cancer. The two types are intravesical chemotherapy, where the drug is put directly into the bladder, and systemic chemotherapy, where the drug enters the bloodstream to reach cancer cells throughout the body.

Chemo can be used before surgery to shrink tumors, after surgery to kill remaining cancer cells, with radiation to improve effectiveness, and as the main treatment for advanced cancers. It is given in cycles of treatment followed by rest periods.

Common chemo drugs for bladder cancer include:

  • Cisplatin
  • Gemcitabine
  • Methotrexate
  • Doxorubicin
  • Paclitaxel
  • Mitomycin
  • Fluorouracil
  • Vinblastine

Common side effects of chemo include:

  • Nausea/vomiting
  • Appetite loss
  • Hair loss
  • Mouth sores
  • Fatigue
  • Increased infections
  • Easy bleeding/bruising

Radiation Therapy for Bladder Cancer

Radiation therapy is a lot like getting an x-ray, although the rays used are stronger. High-energy radiation is directed through a machine outside the body in a process known as External Beam Radiation Therapy (EBRT) to kill cancer cells in the area of the bladder and other parts where it may have spread. Radiation therapy may be used as a supplement to surgery or as a substitute if the patient cannot undergo surgery. It can also be used to preserve the bladder if a cystectomy is to be avoided. Radiation therapy can be combined with chemo drugs in a more potent process called chemoradiation. But this process, although more effective, can also cause faster deterioration and more side effects.

Short-term side effects of radiation therapy may include:

  • Blisters, peeling, and redness in areas getting radiation
  • Nausea and vomiting
  • Frequent urination and bladder discomfort
  • Diarrhea
  • Blood in stool and/or urine
  • Lethargy
  • Lower blood counts

Possible long-term side effects can include:

  • Radiation may cause incontinence or loss of ability to hold in urine
  • Radiation cystitis or damage to the bladder lining
  • Nerve damage which may kill the ability to get erections or feel sexual pleasure

Immunotherapy for Bladder Cancer

Immunotherapy strengthens your immune system to help it effectively fight cancer cells. We’ve discussed Intravesical immunotherapy previously. It is similar to inoculation with standard vaccines, which help trigger an immune response by introducing weakened forms of diseases that will prime the immune system to attack cancer cells more vigorously.

The other method is through the use of immune checkpoint inhibitors. These drugs can turn on or shut off the ‘immune checkpoint proteins’, which are your body’s safety mechanism to prevent the immune system from attacking healthy cells. Since the cancer cells can hide behind immune checkpoints, deactivating them will allow your immune system to better target them.

PD-1 and PD-L1 inhibitors

PD-L1 inhibitors like avelumab (Bavencio) block the PD-L1 protein in cancer cells that help them evade the immune system. This boosts the immune response against cancer cells to potentially shrink or slow tumor growth. Avelumab is used in advanced bladder cancer after chemotherapy or as maintenance therapy, if cancer didn't worsen during initial chemotherapy.

PD-1 inhibitors like nivolumab (Opdivo) and pembrolizumab (Keytruda) block the PD-1 protein in immune T cells. This allows the immune system to attack cancer cells. They are used in advanced bladder cancer after chemotherapy, non-muscle invasive bladder cancer unresponsive to BCG, and as adjuvant therapy for high-risk muscle-invasive bladder cancer after surgery. These drugs are given as intravenous infusions every 2-6 weeks.

These drugs may cause the following side effects:

  • Fatigue
  • Nausea
  • Loss of appetite
  • Fever
  • Urinary tract infections (UTIs)
  • Rash
  • Diarrhea
  • Constipation

Rarely, they may also cause an autoimmune response. Essentially, your immune system goes out of control and will start attacking your healthy cells, damaging your organs. To stop this, you will be given immunosuppressants, usually in the form of corticosteroids. It is important to undergo constant monitoring when getting immunotherapy treatment to make sure this is prevented.

Antibody-drug Conjugates

Antibody-drug conjugates (ADCs) use monoclonal antibodies linked to a chemotherapy drug. The antibody brings the chemo directly to cancer cells with a specific protein target. Once there, the chemo enters and kills the cancer cells.

Enfortumab vedotin targets the Nectin-4 protein in bladder cancer cells. It can be used with pembrolizumab immunotherapy for advanced bladder cancer, or alone if prior platinum chemo and immunotherapy failed. It is infused intravenously weekly for 2-3 weeks then 1 week off. Side effects include fatigue, nerve damage, nausea, taste changes, rash, and high blood sugar. Severe skin reactions and lung inflammation can also occur.

Sacituzumab govitecan targets the Trop-2 protein in cancer cells. It is used for advanced bladder cancer after platinum chemo and immunotherapy. It is infused intravenously weekly for 2 weeks then 1 week off. Common side effects include nausea, vomiting, diarrhea, fatigue, appetite loss, and low blood counts. More serious side effects include severe diarrhea, allergic reactions, and very low white blood cell counts.

Targeted Therapy Drugs for Bladder Cancer

Along with Antibody-drug conjugates, FGFR inhibitors can also be used as a targeted drug therapy for specific cases of bladder cancer.

FGFR inhibitors are a new group of drugs that target fibroblast growth factor receptors, which are proteins that help bladder cancer cells grow.FGFR inhibitors like Erdafitinib can treat advanced bladder cancers with changes in certain FGFR genes when chemotherapy has stopped working. Erdafitinib is taken daily by mouth, and common side effects include mouth sores, fatigue, diarrhea, nausea, and nail changes. More serious side effects can include vision problems, so regular eye exams are needed while on Erdafitinib. Overall, FGFR inhibitors show promise for targeting bladder cancers with specific genetic features.

Erdafitinib was approved in 2019 for treating advanced bladder cancer with FGFR gene changes after chemotherapy; it is a treatment option for metastatic bladder cancer when chemotherapy fails. Taken once daily as a tablet, common side effects include fatigue, mouth sores, nail changes, and eye dryness. Less common but serious risks include kidney or liver problems, severe diarrhea, and vision changes like blurred vision. Patients take Erdafitinib until disease progression or unacceptable toxicity occurs.

If you or a loved one have suffered from a misdiagnosis or delayed diagnosis for your bladder cancer or from negligence that caused more harm during your treatment, contact us at 833-PORTER9, or e-mail us at info@porterlawteam.com to discuss the details of our experience representing other clients and the results we were able to obtain in the past for clients who are suffering as you are. In many ways, our results speak for themselves, and we will stand ready to help you and your family in your time of greatest need.

Last Updated on March 1, 2024 by Michael S. Porter
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