Treatment for Bladder Cancer
Treatment of bladder cancer depends on the stage, type, unifocal/multifocal, performance status of the patient, along with other factors. But the final treatment decision is taken by the oncologist after clinical evaluation of the patient.
Read about risk factors for bladder cancer.
First step is to a cystoscopy. In this technique, a hollow tube called a cystoscope which is fitted with a camera is inserted into the urethra and is slowly advanced into the bladder. It helps to confirm the presence of a bladder tumor and see its location, number, and extent. Also, it helps in transurethral resection of bladder tumor which is both diagnostic and therapeutic.
As you can see in this figure, only cancer containing superficial layers are removed, without damaging the deeper layers.
This helps us to determine whether the bladder tumor is Non-Muscle invasive or Muscle invasive.
Stage 0 Bladder Cancer Treatment
This is carcinoma in situ which is a flat tumor, limited to the epithelium.
should be given in all cases of This disease. As you can see in the figure, in this procedure the chemotherapy drug is directly instilled into the bladder, with the help of a catheter. Ta is the papillary tumor
which is limited to the epithelium.
For Ta disease also, intravesical chemotherapy may be given. But in some cases, intravesical chemotherapy may not be required, when we can keep the patient under observation.
In intravesical therapy, drug is placed directly into the bladder using a catheter. It can produce local action without affecting other body parts. Drugs like mitomycin, valrubicin, docetaxel, thiotepa, and gemcitabine can be given by this technique. Bacillus Calmette-Guerin (BCG) (a modified tuberculosis bacterium) can also be given by this technique, which acts by activating the body’s immune system to destroy cancer cells. The most common side effects associated with intravesical therapy is irritation/burning in the bladder.
A bacterial vaccine– Bacillus Calmette-Guérin (BCG) (generally used to prevent occurrence of tuberculosis) is used in preventing early-stage bladder cancer recurrence. BCG stimulates the immune cells to attack bladder cancer cells.
It is generally employed as intravesical therapy after transurethral resection of bladder tumor (TURBT) or after surgical resection of some early-stage, high-grade, non-muscle invasive bladder cancers to prevent recurrence.
Induction intravesical BCG therapy is usually given once a week for 6 weeks. Two or more rounds of BCG induction therapy may be employed with a treatment-free interval of 4 to 6 weeks. Maintenance therapy with a monthly BCG dosing for about 1 to 3 years may be employed in some patients with high risk of disease recurrence.
Stage 1 Bladder Cancer Treatment
Stage 1 bladder cancer includes cases with T1 disease without any regional lymph nodes involvement or distant spread.
When the tumor infiltrates into the lamina propria, it is called as T1.
For T1 disease, the treatment depends on whether the tumor is low grade or high grade. Intravesical chemotherapy is the treatment of choice for low-grade tumors.
Whereas, in high-grade tumors, apart from intravesical BCG, repeat TURBT is strongly advised.
cases of T1 disease includes those with multifocal lesions, lymphovascular invasion, those associated with carcinoma in situ or having a variant high risk histology (micropapillary, nested or plasmacytoid). It also includes cases that recur after intravesical BCG. In such cases high-risk cases
, the preferred modality of treatment is cystectomy or surgical resection of the bladder.
Stage 2 Bladder Cancer Treatment
Stage 2 bladder cancer includes cases with T2 disease, without the involvement of regional lymph nodes or distant spread of the tumor.
When it infiltrates into the inner muscle layer, it is called as T2a. And T2b, when it infiltrates the outer muscle layer.
For T2 disease, radical cystectomy is advised. It involves cystoprostatectomy in men that includes the removal of bladder, prostate, proximal part of urethra and vas deferens. Whereas, in women, it usually involves the removal of prostate and uterus, along with fallopian tubes, ovaries, part of vagina and urethra. Resection of pelvic lymph nodes is always done in radical cystectomy.
Partial cystectomy is an option in some selected cases, when bladder tumor is located such that it can be removed with adequate margins without removing the complete bladder, eg. tumor at the dome of bladder. Also, there should be no area of carcinoma-in-situ elsewhere in bladder.
Bladder preserving approach may be considered in selected cases depending on size, location, depth of bladder tumor, condition of the patient along with other factors. Treatment in such cases is done with concurrent chemoradiation.
Chemotherapy should be considered in cases of stage 2 disease. It should be preferably given before the surgery (neoadjuvant chemotherapy). If not given in the neoadjuvant setting, then should be given after the surgery (adjuvant chemotherapy).
Stage 3 Bladder Cancer Treatment
Stage 3 includes cases of T3N0M0, T4aN0M0, T1-4aN1-3M0.
Till T2, the tumor is limited to the bladder wall. But when the tumor infiltrates through the bladder wall to involve the perivesical tissue, it is called T3.
And in T4
disease, the tumor infiltrates through the bladder wall to involve the adjacent structures. It may extend downwards to infiltrate prostate gland in males, as you can see in this figure.
Whereas in females, it may extend posteriorly to involve the uterus or vagina
For T3 disease, and selected patients of T4 disease, as discussed above, with nodes negative, the preferred modality of treatment is cystectomy, with chemotherapy, which may be given before or after surgery.
But for non-cystectomy candidates, in which we are not planning surgery, a combination of chemotherapy and radiotherapy may be used.
The tumor may also extend anterolaterally, to involve pelvic or abdominal wall.
This figure shows the pelvic and iliac group of lymph nodes
, which are the regional nodes for a bladder. Depending upon the number and location of the nodes involved, it can be N1, N2 or N3
In selected patients of T4 disease, with abdominal or pelvic wall extension, and any patient with the node-positive disease, the preferred modality of treatment is chemotherapy, with or without radiation therapy. And further therapy maybe decided to depend upon the response to initial treatment.
Stage 4 Bladder Cancer Treatment
Now let’s come to the treatment for stage 4 or metastatic bladder tumor. Distant metastasis from bladder cancer may occur to the bones. Or to the liver in form of multiple nodular deposits.
It may also spread to one or both the lungs
as seen in the figure.
Or to the peritoneum
in form of multiple peritoneal deposits.
Chemotherapy or immunotherapy
is the mainstay of treatment for metastatic disease. But other modalities like surgery, radiation therapy, or bone-directed therapy may be used for palliation or relief of symptoms.
Chemotherapy drugs that are part of bladder cancer treatment regimens are-
Atezolizumab, an PD-L1 inhibitor, has been approved as the first-line therapy for patients with locally advanced or metastatic bladder cancer who are not eligible for any platinum-containing chemotherapy, regardless of the PD-L1 expression level.
Pembrolizumab, Atezolizumab, Nivolumab, Durvalumab, and Avelumab. These immune-checkpoint inhibitors have been approved as the second-line treatment of locally advanced or metastatic urothelial cell carcinoma (most common type of bladder cancer) that has progressed on or after platinum-based chemotherapy. These agents can be employed for the treatment of patients who have progressed within 12 months of neoadjuvant or adjuvant platinum-containing chemotherapy. The PD-L1 expression levels estimation is not a pre-requisite for employing these agents as second-line treatment.
Always remember that metastatic disease is not generally curative. So the intent of the treatment is a prolongation of life, reduction of symptoms, and improvement in the quality of life of the patient.