Treatment Options for Bladder Cancer

Treatment of Superficial Bladder Cancer

Superficial bladder cancer refers to a bladder tumor that is either confined to the transitional epithelium (noninvasive) or has spread only to the lamina propria. The goals of treatment for patients with superficial bladder cancer include:

  • Eradication of the local tumor
  • Prevention of tumor recurrence
  • Prevention of tumor progression to the deeper layers of the bladder and outside of the bladder
  • Preservation of bladder function
  • Maintaining the patient's quality of life

In general, the two treatment modalities used for patients with superficial bladder cancer include:

  • Transurethral resection - a type of surgery used to remove the tumor
  • Intravesical therapy - direct administration of biological agents or drugs into the bladder after the bladder tumor has been resected

Transurethral Resection of the Bladder

Transurethral resection of the bladder tumor (TURBT) represents the primary treatment modality for superficial bladder cancer. During this procedure, which may be performed either under general or regional anesthesia, the tumor is removed using a cystoscope that is inserted into the bladder via the urethra. After surgical removal of the bladder tumor, any remaining cancer cells can be destroyed with either electrical current (fulguration) or with a high-energy laser.

Patients who have undergone TURBT must be followed carefully after the surgery because of the risk of recurrence of bladder cancer. If the cancer recurs rapidly after TURBT, additional surgery may be required or the patient may be treated with intravesical therapy as described in detail below.

Although TURBT is a relative safe and effective procedure, side-effects that may develop include:

  • Bleeding
  • Infection
  • Perforation of the bladder or other nearby organs
  • Increased frequency of urination
  • Urinary incontinence

Intravesical Therapy

The term "intravesical therapy" refers to the instillation of a biological agent or a chemotherapy drug directly into the bladder in order to destroy any residual cancer cells. Intravesical therapy is a form of local drug therapy whereby the treatment is targeted directly at the site of the cancer (bladder) as opposed to systemic drug therapy where a drug is injected into a vein or is given orally and travels throughout the circulatory system in order to reach the target organ (e.g., bladder).

The most common type of intravesical therapy for superficial bladder cancer is immunotherapy with Bacillus Calmette-Guerin (BCG). BCG is a vaccine that is sometimes used to vaccinate people against tuberculosis. The rationale for using BCG for the treatment of superficial bladder cancer is to boost the body's natural immune system to destroy the bladder cancer cells. It is thought that BCG induces regression of the bladder tumor through a non-specific inflammatory reaction at the tumor site. Intravesical therapy with BCG is a form of immunotherapy. Intravesical BCG immunotherapy is the treatment of choice for patients with carcinoma in situ (Stage Tis) where the bladder cancer is limited to the lamina propria of the bladder but has not invaded the surrounding tissue.

Another form of intravesical therapy that may be used for superficial bladder cancer is chemotherapy with an anticancer drug. The most common drug used in the United States for intravesical chemotherapy is Mitomycin C. Other chemotherapy drugs that may be used include:

  • Thiotepa - seldom used in the U.S. due to serious side-effects
  • Doxorubicin
  • Epirubicin
  • Valrubicin - this is the drug of choice for carcinoma in situ (Stage Tis) who do not respond to intravesical BCG immunotherapy
  • Gemcitabine - currently under investigation

Intravesical therapy usually involves weekly instillation of the drug into the bladder via a catheter for 6 to 8 weeks. During each treatment, the patient retains the drug in the bladder for up to two hours after which it is excreted. Subsequent "maintenance" courses of intravesical therapy (i.e., BCG) may be required as deemed necessary by your doctor.

Side-effects associated with intravesical BCG immunotherapy may include:

  • Inflammation of the bladder (cystitis) is the most frequent side-effect and occurs in about 90% of patients
  • Hematuria - occurs in about 30% of patients
  • Fever
  • Malaise
  • Nausea

The most common side-effects associated with intravesical Mitomycin C chemotherapy include:

  • Cystitis - occurs in about 40% of patients
  • Allergic skin reactions - occurs in up to 15% of patients