Treatment & Management

of Bladder Cancer

Treatments for bladder cancer is tailored to each individual and may include surgery, radiation therapy, chemotherapy, use of precision cancer medicines and and immunotherapy.  The specific treatment depends on the stage of the cancer and its genomic profile.

Surgery. Surgery is a common treatment for bladder cancer. The type of surgery depends largely on the stage and the grade of the cancer.

  • Transurethral resection. The doctor may treat early-stage (superficial) bladder cancer with transurethral resection (TUR). During TUR, a cystoscope is inserted into the bladder through the urethra. A small wire loop on the end is used to remove the cancerous area and to burn away any remaining cancer cells with an electric current.
  • Radical cystectomy. For invasive bladder cancer (and when superficial cancer involves a large part of the bladder), the most common type of surgery is radical cystectomy, during which the entire bladder, the nearby lymph nodes, part of the urethra, and the nearby organs that may contain cancer cells—all are removed. In men the prostate, seminal vesicles, and part of the vas deferens are removed. In women the uterus, ovaries, fallopian tubes, and part of the vagina are often removed. If the entire bladder is removed, the patient may undergo another procedure to create a pouch to hold urine. Occasionally, small, localized, muscle-invasive bladder cancers can be removed, sparing the remaining normal bladder in a procedure referred to as partial cystectomy.

Robotic Bladder Cancer Surgery Safe and Effective

Over the past decade, minimally invasive surgical procedures have become an alternative to several types of open surgery. Robotic-assisted radical cystectomy (RARC) is a type of laparoscopic procedure that allows for removal of the cancer without the invasiveness of an open procedure.  Robotic surgery is a major surgical procedure performed in a minimally invasive fashion. It involves sophisticated medical devices that allow surgeons to operate through tiny incisions, using enhanced imagery and incredibly precise movements. Robotic-assisted surgery offers improved, magnified visualization in high-definition 3D. Surgeons are able to precisely control the surgical instruments because they offer seven degrees of free motion.

Some studies have demonstrated that when performed by an experienced surgeon robotic-assisted surgery for invasive bladder cancer is effective and results in less bleeding and shorter hospital stays when compared to the traditional open procedure. 1

Learn more about surgery here.

Radiation therapy. Radiation therapy uses high-powered energy beams, such as X-rays or protons, to kill cancer cells. Radiation therapy may be used alone or with chemotherapy before surgery to shrink the cancer or after surgery to kill any remaining cancer cells.

  • External radiation. This is usually done at least several days per week on an outpatient basis for several weeks. The high-energy rays are concentrated on the cancerous area from outside the body.
  • Internal radiation. This is done by placing a small container of a radioactive substance into the bladder through the urethra or through an incision in the abdomen and requires a hospital stay. Once the implant is removed, no radioactivity is left in the body.

Learn more about radiation here.

Chemotherapy. Chemotherapy uses drugs to kill cancer cells. A single drug or a combination of drugs may be used.  Chemotherapy can be combined with radiation therapy in some situations, since chemotherapy may enhance the effects of the radiation.

For patients with superficial bladder cancer, intravesical (inside the bladder) chemotherapy may be used after TUR. A catheter (tube) is placed through the urethra and into the bladder and used to fill the bladder with liquid forms of the drug(s) used. The drugs are left in the bladder for several hours. This treatment is usually done once a week for several weeks and can then be continued once or several times a month for up to a year.

For cancer that has spread to other parts of the body, chemotherapy drugs may be given intravenously (through a vein that carries the drugs throughout the body). The drugs are usually given in cycles so that a recovery period follows every treatment period. Occasionally, chemotherapy is also given before bladder surgery (cystectomy) as a means to facilitate surgery by reducing the tumor bulk. This is known as neoadjuvant therapy and has demonstrated survival benefit for many patients needing a radical cystectomy.

Precision Cancer Medicine

The purpose of precision cancer medicine is not to categorize or classify cancers solely by site of origin, but to define the genomic alterations in the cancers DNA that are driving that specific cancer. Precision cancer medicine utilizes molecular diagnostic testing, including DNA sequencing, to identify cancer-driving abnormalities in a cancer’s genome. Once a genetic abnormality is identified, a specific targeted therapy can be designed to attack a specific mutation or other cancer-related change in the DNA programming of the cancer cells. Precision cancer medicine uses targeted drugs and immunotherapies engineered to directly attack the cancer cells with specific abnormalities, leaving normal cells largely unharmed.

Keytruda (pembrolizumab) is a precision cancer immunotherapy that helps to restore the body’s immune system in fighting cancer. It creates its anti-cancer effects by blocking a specific proteins used by cancer cells called PD-1 and PD-L1, to escape an attack by the immune system. Once PD-L1 is blocked, cells of the immune system are able to identify cancer cells as a threat, and initiate an attack to destroy the cancer.  There are several PD-1 and PD-L1 inhibitors that work in bladder cancer and they are collectively referred to as “checkpoint inhibitors”.2,3,4,5

  • Keytruda
  • Imfinzi (durvalumab)
  • Tecentriq (atezolizumab)
  • Bavencio (avelumab)
  • Opdivo (nivolumab)

A clinical study that compared the Keytruda to standard chemotherapy in recurrent bladder cancer that had recurred or progressed following platinum-based chemotherapy demonstrated improved outcomes with the checkpoint inhibitor. 2

Patients who expressed higher levels of the PD-L1 protein have been demonstrated to experience a greater anti-cancer response than those who expressed lower PD-L1 levels.3,4

Immunotherapy uses the body’s natural ability (immune system) to fight cancer and is used for the treatment of superficial bladder cancer following TUR and for the treatment of more advanced cancers.  For superficial bladder cancer immunotherapy can be used within a few weeks of TUR surgical removal of the cancer.

  • Bacillus Calmette-Guerin (BCG). This is the most common form of immunotherapy. BCG solution contains live, weakened bacteria related to cow tuberculosis that stimulate the immune system to kill cancer cells in the bladder. The bladder is filled with the solution through a catheter and left for about two hours. Patients generally undergo this treatment once a week for about six weeks.
  • Interferon. This is another form of biologic therapy, which involves the administration of large amounts of a synthetic protein normally made by the body to activate and energize the immune system. Recent studies suggest that a combination of BCG plus interferon may be particularly active against aggressive or refractory superficial bladder cancer, especially CIS.

Treatment of Bladder Cancer by Stage

Stage 0 (T0): Patients with stage 0 bladder cancer have the earliest stage of cancer that involves only the innermost layers of cells in the bladder. Depending upon the appearance of the cells under the microscope, stage 0 transitional bladder cancer is pathologically classified as either noninvasive papillary carcinoma or carcinoma in situ (CIS), both of which are considered to be “superficial” bladder cancers.

Stage I (T1): Patients with stage I bladder cancer have cancer that invades beneath the surface of the bladder into connective tissue, but does not invade the muscle of the bladder and has not spread to lymph nodes. This is also classified as a “superficial bladder cancer.”

Stage II (T2): Patients with stage II bladder cancer have cancer that invades through the connective tissue into the muscle wall, but has not spread outside the bladder wall or to local lymph nodes. Patients with cancer invading the inner half of the muscle of the bladder wall have a better outcome than patients with invasion into the deep muscle (outer half of the muscle of the bladder wall). Stage II bladder cancer is classified as a “deep” or “invasive” bladder cancer.

Stage III (T3): Patients with stage III bladder cancer have cancer that invades through the connective tissue and muscle and into the immediate tissue outside the bladder and/or invades the prostate gland in males or the uterus and/or vagina in females. With stage III bladder cancer, there is no spread to lymph nodes or distant sites. Stage III bladder cancer is also classified as a “deep” or “invasive” bladder cancer.

Stage IV (T4): Patients with stage IV bladder cancer have cancer that has extended through the bladder wall and invaded the pelvic and/or abdominal wall and/or has lymph node involvement and/or spread to distant sites. Stage IV bladder cancer is also referred to as “metastatic” bladder cancer. Recurrent Bladder Cancer: Patients with recurrent bladder cancer have cancer that has returned following initial treatment with surgery, radiation, chemotherapy or immunotherapy.

Recurrent: Patients with recurrent bladder cancer have cancer that has returned following initial treatment with surgery, radiation, chemotherapy or immunotherapy.

Next: Stage 0 of Bladder Cancer

References


1 Parekh DJ, Messer J, Fitzgerald J, et al. Perioperative outcomes and oncologic efficacy from a pilot prospective randomized clinical trial of open versus robotic assisted radical cystectomy. Journal of Urology. 2013; 189(2): 474-479.

2 http://investors.merck.com/investors/financial-news/press-release-details/2016/Mercks-KEYNOTE-045-Studying-KEYTRUDA-pembrolizumab-in-Advanced-Bladder-Cancer-Urothelial-Cancer-Meets-Primary-Endpoint-and-Stops-Early/default.aspx

3 United States Food and Drug Administration. (2016.) News Release. FDA approves new, targeted treatment for bladder cancer.

4 https://www.fda.gov/drugs/informationondrugs/approveddrugs/ucm555930.htm

5 http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm501762.htm. Accessed May 31, 2016.