Options to treat your muscle invasive or metastatic bladder cancer can depend largely on tumor stage. It's measured by the size and how far the tumor has spread.
For bladder cancer, the main thing your doctor looks for is how deep the tumor grows into the muscle wall that surrounds your bladder. With muscle invasive bladder cancer, the tumor has grown into the muscle wall around your bladder. And if the cancer is in other body parts or organs outside of your bladder, it's called metastatic bladder cancer.
Therapies for advanced stage bladder cancer show promise. Your doctor may add certain medicines and procedures together for added benefit.
"Today there are many more [successful full-body] treatment options to delay progression of the tumor," says Roger Li, MD, a genitourinary oncologist who treats bladder and prostate cancers at Moffitt Cancer Center in Tampa, Florida. "And in some cases, even cure the disease."
Treating Muscle Invasive Bladder Cancer
After your doctor puts all the testing information together, they'll give you a stage ranging from 0 to IV. The higher numbers mean larger tumors that have spread further.
At stage III, the tumor has grown outside your bladder and into nearby tissues, organs, or lymph nodes. Stage IV means the cancer has reached distant parts of your body.
Transurethral resection of the bladder tumor (TURBT)
During a TURBT, your doctor can do a biopsy. They'll take a small piece of muscle tissue to stage and confirm your bladder cancer.
Your doctor inserts thin instruments into your bladder through your urethra – the tube where your urine exits the body. They can also remove any tumors in the lining of your bladder.
Because the cancer has already gotten into the muscle wall, by itself, a TURBT isn't a cure. But the surgery can help your doctor know how far the cancer has spread.
Next, you and your doctor can decide on the best treatment steps.
Combining Medication With Surgery
Treatment for muscle invasive bladder cancer often includes medicine before surgery – it's called neoadjuvant therapy. Most people get medication such as cisplatin followed by surgery.
Your doctor may remove:
- Part of your bladder with a partial cystectomy, if your tumor is limited to one area
- All of your bladder, called radical cystectomy
If cisplatin doesn't work for you, your doctor will discuss other treatment options. Anticancer medications before surgery can help:
- Shrink your tumor as much as possible
- Lower the risk of spread beyond the bladder
- Give you a greater chance of a cure after surgery
Combined treatment options for muscle invasive and metastatic bladder cancer
Staying fit and eating a well-balanced diet can help you prepare for cisplatin treatment.
Then, you'll continue to take durvalumab after a radical cystectomy to help prevent the cancer from coming back. Some studies showed a higher chance of survival after this treatment, compared to taking chemotherapy alone. Durvalumab can help:
- Block the PD-L1 protein found on cell surfaces
- Unmask tumor cells
- Help your immune system find, attack, and kill bladder cancer cells
When cisplatin isn't an option, immunotherapy with or without an ADC before removing your bladder may be. After surgery, you'll continue taking the combined medicines to lower the risk of bladder cancer recurrence.
Enfortumab vedotin can also cause skin problems for some people, and you may get:
- Dry or cracked skin
- Painful blisters on your midsection
- Scaly hands or feet
- Red or irritated skin
- Sore, swollen, or painful skin
Bladder Removal
You may have surgery to remove all or part of your bladder. Taking your bladder out can lower your risk of bladder cancer spreading.
Your doctor will take out the tumor and your bladder using a cystectomy:
- With a cut made in your lower belly, also called open surgery
- With long, thin tools using tiny cuts in your belly, known as laparoscopic surgery
After your bladder is removed, a procedure called a urinary diversion helps you pass urine (pee) in a new way.
Things to think about after bladder removal
A cystectomy can change your life and the way you urinate. But working with your cancer care team can help most issues get better.
Here are some things to consider and help you prepare for surgery.
How often you pee. It can depend on your treatment, but for a:
- Partial cystectomy, you may simply have to go more often.
- Radical cystectomy, you may no longer urinate the way you used to — meet with your ostomy nurse to learn how to change your bag and care for your stoma.
Changing the way your body passes urine not only brings an emotional toll; it can also come with the risk of complications. For instance, urine can leak out and irritate your skin. Try using skin barrier paste to protect any sensitive areas.
Let your doctor know about any:
- Pain
- Drainage
- Constipation
- Nausea
Higher risk of sexual problems. Bladder removal can come with the risk of sexual side effects, too.
If you have a penis, the surgery includes:
- Removal of the prostate and the glands that secrete many of the components of semen.
- After the surgery, you may no longer make semen but still have an orgasm without ejaculating.
If you have a vagina, the surgery typically removes:
- Part of the vagina, which can make sex uncomfortable.
- And if the nerves running along both sides of your vagina are damaged, it may impact your ability to have an orgasm.
Vaginal reconstruction may be an option and a potential solution to sexual discomfort. But even without repairing your vagina, there are ways to make sex comfortable after recovery from surgery.
Talk about sparing your nerves.Nerve damage during the surgery can lead to:
- Temporary or long-term erectile dysfunction
- And if the end of the urethra is removed, it can reduce blood flow to the clitoris and interfere with sexual arousal
Before surgery, discuss whether these nerves can be left intact at the end of your urethra.
Typically, the younger you are when you have the surgery, the more likely you are to eventually regain full function. Resuming sexual activity with a urostomy can also be challenging and require a period of adjustment. Your doctor can help you review your options and know what to expect.
When There's a Choice: Trimodality Therapy (TMT)
If taking out your bladder isn't an option, you might consider bladder-preserving treatment, which keeps your bladder. Trimodality therapy (TMT) involves:
- Cemotherapy
- Radiation
- Surgery to remove the tumor
TMT can help save your bladder but isn't right for everyone. Bladder removal is a life-changing surgery. But with bladder cancer, keeping it can mean a lifelong commitment to follow-up.
Long-term monitoring for bladder cancer
For muscle invasive bladder cancer, treatments before surgery work so well that "many patients are wondering whether it's necessary to remove the bladder following systemic therapy," says Li. "And whether radiation can provide the same treatment benefit."
If you're given a choice, an intact bladder may help improve your quality of life in the near term.
Keeping your bladder "will help avoid the complications and morbidities that come with radical cystectomy," says Li "But the need for surveillance, risk of tumor recurrence, and morbidities associated with bladder preservation are often underappreciated."
After a more extensive TURBT followed by chemoradiation, you'll need lifelong monitoring for recurrence. To help prevent complications, your doctor will help you put together a follow-up plan.
Removal can lower the risk of bladder cancer coming back
Of the two options, "radical cystectomy is typically the more definitive route to eradicate the disease," says Li. " With the bladder removed, there is no concern about local recurrence [in the future] that could progress to metastatic disease."
Treating Molecular Residual Disease
After treatment, your doctor will run tests to check for any traces of cancer cells in your blood. Any cancer cells left over are called molecular residual disease. If your doctor finds any circulating tumor DNA (ctDNA) on your blood test, they may suggest taking immunotherapy.
Immunotherapy can help lower your risk of bladder cancer coming back and provide treatment if you didn't get chemotherapy before surgery.
Common side effects for nivolumab
- Rash
- Fatigue
- Diarrhea
- Muscle pain
- Itching
Changes in your eyesight can include seeing flashes or sparks of light, floating spots, or a veil over part of your vision.
Some common side effect for atezolizumab
- Pain in your back, neck, arm, or leg
- Difficulty moving
- Change in taste or loss of taste
- Thinning hair or hair loss
- Weakness in your arms, hands, legs, or feet
If these side effects are ongoing or very bothersome, talk to your care team. Your doctor can adjust your dose or talk to you about other options.
Treating Stage IV Metastatic Bladder Cancer
Stage IV bladder cancer may have reached your:
- Pelvic or abdominal (belly) wall
- Distant lymph nodes
- Distant organs
It can be harder to treat, but expanding therapies can really slow progression and extend life.
"The agents we use in metastatic bladder cancer have drastically increased in efficacy," Li says. This means the options today can work better to kill bladder cancer that has spread.
Discussing Treatment Options
Consider asking these questions about your bladder cancer treatment plan:
- What's my therapy goal? To shrink the cancer, slow its growth, ease symptoms, or help me live longer?
- Why are you suggesting this medicine instead of another option?
- Can I get bladder-preserving treatment? How would that impact my life?
- How would bladder removal impact my life?
- If I'm having my bladder removed, can I get a neobladder to continue passing urine the usual way?
- How will this treatment affect my daily life, energy, appetite, pain, or ability to work or travel?
- What side effects are most likely with this treatment, and which ones should I call about right away?
- How long will I take this medicine and know if it's working?
- What happens if the cancer grows or this treatment stops working?
Remember this
"We have various ways to provide direct tumor kill," says Li. Treatments now "engage the immune system to slow down the progress of the disease and achieve cure in some instances." The growing number of options to treat bladder cancer today is a sign of progress.
"Science is advancing at an unprecedented pace," says Li. "The more we understand the disease, the better we will be able to treat it and to innovate upon the current standards."
Show Sources
Photo Credit: E+/Getty Images
SOURCES:
Roger Li, MD, genitourinary oncologist, Moffitt Cancer Center, Tampa, Florida.
Mayo Clinic: "Bladder Cancer," "Pembrolizumab (intravenous route)," "Enfortumab vedotin," "Nivolumab (intravenous route)."
American Cancer Society: "Treatment of Bladder Cancer Based on the Stage and Other Factors," "Bladder Cancer Surgery."
Current Drug Targets: "Neoadjuvant Chemotherapy Before Radical Cystectomy: Why We Must Adhere?"
Cancer Research UK: "MVAC," "Durvalumab (Imfinzi)."
FDA: "FDA approves durvalumab for muscle invasive bladder cancer," "Keytruda package insert."
National Cancer Institute: "Pembrolizumab."
Cleveland Clinic: "Antibody drug conjugates (ADCs)."
BCAN: "Bladder Cancer Basics," "What Can I Expect When I Get Home?"
