Patient education: Bladder cancer treatment; invasive cancer (Beyond the Basics)
- Andrew J Stephenson, MD
Andrew J Stephenson, MD
- Associate Professor
- Cleveland Clinic Lerner College of Medicine
- Chief, Section of Urologic Oncology
- Glickman Urological and Kidney Institute
BLADDER CANCER OVERVIEW
Cancer of the urinary bladder is one of the most common cancers. The most common type of bladder cancer in the United States and western Europe is urothelial carcinoma, also known as transitional cell carcinoma (TCC). The optimal treatment for urothelial bladder cancer depends upon the cancer's stage and grade, and also on the health of the patient.
●Approximately 70 percent of all new cases of bladder cancer are classified as non-muscle-invasive or superficial. The initial treatment for superficial bladder cancer is surgical removal of the tumor through a cystoscope (called "transurethral resection of bladder tumor," or TURBT). This is often followed by adjuvant (additional) therapy, which reduces the chances of the cancer recurring. (See "Patient education: Bladder cancer treatment; non-muscle invasive (superficial) cancer (Beyond the Basics)".)
●The remaining 30 percent are muscle-invasive bladder cancers, and generally require surgical removal of the bladder (cystectomy) and some surrounding organs. In some cases, successful treatment of the bladder cancer may be accomplished without removing the entire bladder. Bladder-sparing treatments, such as radiation and chemotherapy, may be combined with TURBT, partial bladder removal, or an extensive endoscopic removal (termed radical TURBT) and may achieve acceptable cure rates as an alternative in select patients. (See 'Cystectomy (surgical removal of the bladder)' below and 'Bladder preservation' below.)
This article will review the treatment of invasive urothelial bladder cancer. The diagnosis and staging of bladder cancer, and the treatment of superficial bladder cancer are discussed separately. (See "Patient education: Bladder cancer diagnosis and staging (Beyond the Basics)" and "Patient education: Bladder cancer treatment; non-muscle invasive (superficial) cancer (Beyond the Basics)".)
More detailed information about bladder cancer, written for healthcare providers, is available by subscription. (See 'Professional level information' below.)
WHAT IS INVASIVE BLADDER CANCER?
Bladder tumors are staged using the TNM system, which indicates how deeply the tumor has penetrated (T stage), whether it has reached the nodes (N), and whether it has spread or metastasized to other parts of the body (M). These stages are then grouped as 0 (least advanced) through IV (most advanced), and this helps the doctor to decide what type of treatment to use.
Invasive bladder cancer is stage T1 or greater, meaning that the tumor has invaded the lining of the bladder. T1 designates tumors that have invaded the superficial lining of the bladder (known as the lamina propria) without involving the muscle layer (known as the muscularis propria). If the tumor has invaded the muscle layer of the bladder, it is stage T2. Stage T3 cancer has grown through the bladder muscle into the fat layer surrounding the bladder, while stage T4 cancer has spread to nearby organs.
BLADDER CANCER TREATMENT OPTIONS
The standard treatment for muscle-invasive bladder cancer includes surgery to remove the bladder and nearby organs (called radical cystectomy) (see 'Cystectomy procedure' below). Lower stage invasive bladder cancer (stage T1 tumors) may be treated with radical cystectomy or intravesical Bacillus Calmette-Guerin (BCG). (See "Patient education: Bladder cancer treatment; non-muscle invasive (superficial) cancer (Beyond the Basics)", section on 'Intravesical BCG'.)
Radical cystectomy requires the creation of a new way to get rid of urine (see 'Where will the urine go?' below). In some cases, it is possible to avoid cystectomy by having a bladder-preserving treatment. However, this treatment is not an option for most people with muscle-invasive bladder cancer due to the high-risk that the cancer will come back (called a recurrence).
For people with muscle-invasive bladder cancer who are able to tolerate more aggressive treatment, chemotherapy is often given before surgery (called neoadjuvant chemotherapy).
Which treatment is best? — The best treatment for invasive bladder cancer depends upon the person's age, underlying medical problems, stage of the bladder cancer, and personal preference. When possible, surgical removal of the bladder is preferred because it has a lower chance of cancer recurrence and better chance of survival compared to other treatments. However, preserving the bladder may be an option in selected cases.
Cystectomy is preferred for people who have:
●Invasive bladder cancer and are not candidates for bladder preservation
●Low-stage or superficial cancer that has recurred after intravesical BCG
●High-grade T1 cancers (intravesical BCG is a reasonable alternative) – A tumor's grade describes how aggressively it grows.
Bladder preservation may be an option for people who:
●Are elderly, or who have serious underlying medical problems and would not be able to tolerate a major surgery
●Strongly prefer to keep their bladder AND have a single, well-defined, muscle-invasive tumor inside the bladder, without any evidence of cancer on the inner lining (which is called "carcinoma in situ" and often recurs) or hydronephrosis (enlargement of the kidneys). Ideally, these tumors should be amenable to a complete removal by transurethral resection of bladder tumor (TURBT). (See 'Radical transurethral resection of bladder tumor (TURBT)' below.)
CYSTECTOMY (SURGICAL REMOVAL OF THE BLADDER)
The survival of people with muscle-invasive bladder cancer who need to have cystectomy is optimized if they receive chemotherapy before surgery, and the combination of preoperative chemotherapy and surgery is widely recognized as the standard of care. However, preoperative chemotherapy is reserved for people who are healthy enough to tolerate this more aggressive treatment.
Neoadjuvant chemotherapy — Chemotherapy refers to the use of medicines to stop or slow the growth of cancer cells. "Neoadjuvant" in this case means it is given prior to surgery. When possible, people with muscle-invasive bladder cancer should be advised to have neoadjuvant chemotherapy before cystectomy.
Chemotherapy works by interfering with the ability of rapidly growing cells (such as cancer cells) to divide or reproduce themselves. Because most of an adult's normal cells are not rapidly growing, they are not affected by chemotherapy. Exceptions to this include cells of the bone marrow (where the blood cells are produced), the hair, and the lining of the gastrointestinal tract. These tissues are affected most by chemotherapy, causing the typical side effects (low blood counts, hair loss, nausea, etc).
The reason neoadjuvant chemotherapy is recommended is that it helps to eliminate undetectable cancer cells that are often found in other areas of the body in people with invasive cancer. By eliminating these cancer cells, chemotherapy helps to improve survival. Clinical trials have shown that neoadjuvant chemotherapy reduces the risk of death and improves five-year survival in people with invasive bladder cancer .
Cisplatin-based, multi-agent chemotherapy is usually given in this setting. Two regimens that are most often employed include a combination of four drugs methotrexate, vinblastine, doxorubicin, and cisplatin (abbreviated MVAC) or cisplatin plus gemcitabine (GC). The regimen is usually given by vein. If you are receiving MVAC, an overnight stay in the hospital may be needed.
These combinations are given in cycles. A cycle of chemotherapy refers to the time it takes to give the treatment and then allow the body to recover from the effects. During this time, you are closely monitored for signs of drug toxicity and side effects. Three cycles of MVAC or GC are usually recommended before cystectomy. Regimens containing carboplatin (a different chemotherapy agent) are considered inferior to cisplatin-based regimens and are not recommended.
Chemotherapy side effects — The most common side effects of MVAC include fatigue, increased risk of infection, bruising or bleeding easily, complete hair loss, mouth soreness, nausea or vomiting (which usually can be prevented or treated), decreased hearing or ringing in the ears, numbness or tingling in the hands or feet, and pink-red colored urine. These side effects are usually temporary and resolve after treatment is completed.
Cystectomy procedure — Radical cystectomy includes removal of the bladder, nearby organs, and associated lymph nodes.
●In men, radical cystectomy generally includes removal of the bladder, as well as the prostate and seminal vesicles (figure 1). Because of the extent of the surgery, nerve damage can occur, leading to erectile dysfunction (inability to have or maintain an erection). However, nerve-sparing techniques have been developed to preserve the cavernous nerves to enable men the potential of recovering sexual function after cystectomy. (See 'Nerve-sparing procedures' below.)
●In females, radical cystectomy usually involves removal of the bladder, as well as the uterus, cervix, and upper vagina (figure 2).
Where will the urine go? — After your bladder is removed, the surgeon must create a new place for urine to be collected. This is called a urinary diversion. All options involve using a segment of bowel, which is removed from the small or large intestine. After removing a segment of bowel, the intestines are reattached so that they function normally. The section of bowel that is removed is cleaned and prepared.
There are several possible options at this point:
●Urine can be diverted through a segment of bowel to the skin's surface, where an opening (called a stoma) is created. A bag is attached to the stoma to collect the urine. This is called a non-continent cutaneous diversion or ileoconduit (figure 3).
●A reservoir (like a pouch) may be created under the skin of the abdomen using tissue from the stomach or intestines. Urine collects in the pouch, and you use a catheter (a thin tube) to empty the pouch periodically. It is not necessary to wear a bag. This is called a continent cutaneous diversion, commonly called an Indiana pouch (figure 4).
●A new bladder may be created from a segment of bowel. The new bladder is connected to the urethra, allowing the person to urinate normally. This is called an orthotopic neobladder, commonly called a neobladder or Studer pouch (figure 5).
The "best" type of urinary diversion depends upon your and your surgeon's preference, as well as the extent of the cancer. In addition, the continent reservoir and neobladder require a person to learn how to self-catheterize; people who would have difficulty handling or placing the catheter may not be good candidates for these procedures.
Complications of urinary diversion — Some potential complications of urinary diversion include leakage of urine, urinary tract infection, skin irritation (with stoma or pouch), and narrowing or closure of the tissue where urine exits. The risk of each of these depends upon which procedure is performed. To understand the risks and benefits of each type of diversion, talk with your surgeon.
Lymph node removal — Lymph fluid from the bladder normally drains into lymph nodes (glands) located in the pelvis. If your cancer has spread to lymph nodes, there is a much higher risk that the cancer has also spread elsewhere. This significantly increases the risk of the cancer recurring at a later time.
An important part of radical cystectomy is removal of all lymph nodes that could contain tumor cells. This includes lymph nodes in the pelvic region, and in some cases, also includes more distant lymph node groups. Talk to your surgeon about which nodes will be removed as there is increasing evidence that removing more lymph node groups (rather than the standard groups) may improve survival .
Men — In men, surgical removal of the bladder, prostate, and seminal vesicles (figure 1) can damage the nerves responsible for achieving and maintaining an erection. Men who want to preserve their ability to have an erection are sometimes able to have a nerve-sparing surgery, which reduces the risk of nerve damage. This procedure is only available to men who have no evidence of cancer in the bladder neck or prostatic urethra, no carcinoma in situ (cancer affecting the inner lining of the bladder), and no evidence of prostate cancer.
Approximately 30 to 50 percent of men who have nerve-sparing cystectomy are able to have an erection sufficient for sexual intercourse one to two years after surgery . Most of these men will require an oral medication, such as sildenafil (brand name: Viagra), to have an erection. (See "Patient education: Sexual problems in men (Beyond the Basics)".)
One potential risk of nerve-sparing surgery is that an insufficient amount of cancerous tissue will be removed from around the nerves. However, several studies have shown that bladder cancer recurrence rates are similar in men who have nerve-sparing and traditional radical cystectomy when patients are carefully screened before surgery .
Women — In women, nerve-sparing surgery involves careful removal of tissue on each side of the vagina, where nerves responsible for sexual function are found. Nerve-sparing surgery may help to prevent vaginal dryness, pain with intercourse, and loss of the ability to have orgasm.
Surgical complications — Up to 60 percent of people who have radical cystectomy and urinary diversion develop some type of complication. The most common serious complications include infection, wound opening, bleeding, and blood clots in the lungs (pulmonary embolism). The surgeon's and hospital's experience in performing cystectomy, as well as the your age and any underlying medical problems, affect your risk of developing complications.
Chemotherapy after cystectomy — In some situations, chemotherapy is not given before cystectomy. However, for these people, chemotherapy may be recommended after surgery (called adjuvant chemotherapy) if more extensive disease is found when the bladder is removed. For example, chemotherapy may be recommended after cystectomy for those healthy enough to tolerate it if:
●The tumor extends into the layer of fat (called perivesical fat) surrounding the bladder (tumor stage T3 or higher)
●Cancerous cells are identified in the lymph nodes that were removed during the cystectomy
The best chemotherapy regimen is not clear; patients are encouraged to enroll in a clinical trial if possible. (See 'Clinical trials' below.)
Outcomes — The outcomes following radical cystectomy for bladder cancer depend upon the stage and extent of the cancer and lymph node involvement . Talk to your doctor or nurse if you have questions about your cancer.
In selected people with invasive bladder cancer, it may be possible to avoid removing the entire bladder. The possible risk of this approach is that the bladder cancer may be more likely to recur.
Bladder preservation options include:
●Chemotherapy and radiation (chemoradiotherapy), which is performed after radical transurethral resection of bladder tumor (TURBT)
●Partial removal of the bladder
Risk of recurrence with bladder preservation — Between 30 to 60 percent of people who have bladder preservation will develop recurrent bladder tumors, approximately half of which are invasive. If this occurs, the recommended treatment is cystectomy.
Overall survival in people who develop a recurrence and then undergo cystectomy is 40 to 50 percent; this is probably 10 to 20 percent lower compared with immediate treatment with radical cystectomy. This is important to consider when deciding upon a treatment plan.
Chemoradiotherapy — Chemoradiotherapy is a treatment that involves using radiation therapy to the bladder and pelvis along with chemotherapy. Removal of all visible evidence of cancer with TURBT is recommended before proceeding to chemoradiation (see 'Radical transurethral resection of bladder tumor (TURBT)' below). Chemoradiation is less likely to be successful in people who have residual cancer in the bladder at the start of therapy.
Radiation therapy involves the use of focused high-energy X-rays to destroy cancer cells. The X-rays are delivered from a machine that directs the X-rays at your body. The damaging effect of radiation is cumulative, and a certain dose is required to stop the growth of cancer cells. In order to accomplish this, small radiation doses are administered for a few seconds each day (similar to having an X-ray) five days per week for several weeks. Treatment is not painful.
A chemotherapy drug, such as cisplatin or mitomycin C plus fluorouracil, is usually given once every three weeks into a vein during radiation therapy. Chemotherapy makes the tumor cells more sensitive to the radiation treatment, improving the chance of eliminating the cancer. The combination of chemotherapy and radiation therapy is associated with improved cancer control in the bladder and pelvic region compared to radiation therapy alone.
Radical transurethral resection of bladder tumor (TURBT) — Radical TURBT is a procedure in which a physician uses a cystoscope to view the lining of the bladder and remove any abnormal-appearing areas. This is similar to the procedure used to treat superficial bladder cancer.
However, radical TURBT is more aggressive than standard TURBT; the physician will remove any abnormal appearing areas, as well as the underlying bladder muscle, down to the layer of fat surrounding the bladder (called perivesical fat).
Several weeks after the radical TURBT, the physician will use the cystoscope to look inside the bladder again. If there is no evidence of cancer, you will be followed closely.
If there is evidence of cancer after the radical TURBT, surgical removal of the bladder is usually recommended, sometimes with neoadjuvant chemotherapy given before surgery. (See 'Cystectomy procedure' above.)
Partial bladder removal (partial cystectomy) — Partial cystectomy is a surgical procedure in which the bladder tumor and some surrounding bladder tissue are removed, allowing the person to keep the healthy tissue. The surgery is done through a midline (up and down) incision in the lower abdomen. Removal of involved lymph nodes is also performed. (See 'Lymph node removal' above.)
Partial cystectomy is not an option for most people but may be available for people with certain characteristics, including a single small tumor at the top of the bladder or within a bladder diverticulum. People who have recurrent bladder cancer or involvement of other areas (urethra, lower bladder) are not good candidates for partial cystectomy.
The advantage of partial cystectomy is that it allows the person to urinate "normally" after surgery and does not usually interfere with sexual function. The disadvantage is that there is a higher risk of bladder cancer recurrence. Approximately 70 percent of patients survive long-term after partial cystectomy .
TREATMENT OF METASTATIC CANCER
Some people will develop metastatic cancer, meaning that the cancer has spread (metastasized) to other parts of the body. Chemotherapy is usually the first treatment in this situation. Immunotherapy drugs (medications that work with your immune system to attack cancer cells) are also sometimes used for the treatment of metastatic bladder cancer if chemotherapy is no longer working.
Progress in treating cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials, or read about clinical trials at:
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Overview of the initial approach and management of urothelial bladder cancer
Clinical presentation, diagnosis, and staging of bladder cancer
Neoadjuvant treatment options for muscle-invasive urothelial bladder cancer
Radical cystectomy and bladder-sparing treatments for urothelial bladder cancer
Urinary diversion and reconstruction following cystectomy
Bladder preservation treatment options for muscle-invasive urothelial bladder cancer
The following organizations also provide reliable health information:
●National Cancer Institute
●The National Library of Medicine
●American Society of Clinical Oncology
●Raghavan D, Tuthill K. Bladder Cancer: A Cleveland Clinic Guide for Patients, Cleveland Clinic Press/Kaplan Press, Cleveland 2008.
- Advanced Bladder Cancer Meta-analysis Collaboration. Neoadjuvant chemotherapy in invasive bladder cancer: a systematic review and meta-analysis. Lancet 2003; 361:1927.
- Leissner J, Ghoneim MA, Abol-Enein H, et al. Extended radical lymphadenectomy in patients with urothelial bladder cancer: results of a prospective multicenter study. J Urol 2004; 171:139.
- Kessler TM, Burkhard FC, Perimenis P, et al. Attempted nerve sparing surgery and age have a significant effect on urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. J Urol 2004; 172:1323.
- Schoenberg MP, Walsh PC, Breazeale DR, et al. Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10-year followup. J Urol 1996; 155:490.
- Shariat SF, Karakiewicz PI, Palapattu GS, et al. Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium. J Urol 2006; 176:2414.
- Holzbeierlein JM, Lopez-Corona E, Bochner BH, et al. Partial cystectomy: a contemporary review of the Memorial Sloan-Kettering Cancer Center experience and recommendations for patient selection. J Urol 2004; 172:878.
- Raghavan D, Tuthill K. Bladder Cancer (Cleveland Clinic Guide), Bladder Cancer (Cleveland Clinic Guide), Cleveland 2008.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.