Bladder Preservation Treatment Options

BLADDER PRESERVATION

Although complete removal of the bladder for muscle-invasive bladder cancer has been the “gold standard” for many decades, it’s now accepted that bladder preservation is a safe alternative for carefully selected patients.

The bladder-preserving approach to the treatment of muscle-invasive bladder cancer is usually a combination of three treatments – radiation therapy, chemotherapy and complete TURBT. The combination of these three treatments is called “trimodal therapy,” which we’ll call TMT.

As you’re probably familiar with the TURBT, which you would have had during diagnosis, we won’t explain this treatment here. In a moment, we’ll talk a bit more about radiation and chemotherapy, but let’s start by discussing whether you may qualify for TMT or a partial removal of the bladder.

WHO QUALIFIES FOR TMT?

Not every bladder tumour is suitable for TMT. Your medical team will help you make a treatment decision to determine what is best for you, based on several important factors.

Radiation is less effective if the bladder tumour is too bulky. This means that TMT is not recommended if it measures more than 5 cm (about 2 inches), can be felt by the physician during a physical examination, or if the tumour causes blockage of urine flow from one or both kidneys (called “hydronephrosis”).

Radiation is also less effective if there are cancer cells in multiple areas of the bladder or if they’re associated with areas of “carcinoma in situ” (a cancer stage called Cis or Tis). These are flat tumours (see the illustration here). This is because of the increased risk of recurrence of the cancer.

It’s also important that you have good bladder function before starting TMT. If you have a lot of problems with frequent and urgent urination, TMT might not be suitable.

In up to 25% of patients, cancer remains in the bladder despite TMT. In this case, complete removal of the bladder is then required and a path to divert the urine to the outside of the body is created.

If complete removal of the bladder is needed, the option for a “neobladder” would not be recommended. This is because radiation delivered during TMT can affect the small bowel and the area of the sphincter (the valve that opens and closes to allow urine to leave the body), even with the best choice of dose and targeting. As a result, there is an increased risk of incontinence, although some patients who receive a neobladder even after radiation can be continent.

THE PARTIAL CYSTECTOMY OPTION

We should mention at this point that there may be an option for a small number of patients in very specific situations to remove only a part of the bladder (called a “partial cystectomy”). While removal of part of the bladder has the normal risks associated with surgery, it preserves urinary and sexual function and avoids the need to replace the bladder with a section of bowel.

The bladder is roughly triangular in shape. There is a “roof” or “dome” at the top of the bladder, and side walls tapering down to the “neck” where urine leaves the body through a tube called the “urethra.”

Partial cystectomy is generally considered only in carefully selected patients with a single tumour located on the dome or high up on the side walls, in particular those with a rare form of bladder cancer called “adenocarcinoma,” a type of cancer that begins in the cells that produce mucous.

The tumour should not be greater than 3 centimeters (just over 1 inch), and there should be no “carcinoma in situ” (a cancer stage called Cis or Tis). These are flat tumours.

You should have good bladder capacity if you’re being considered for partial cystectomy. The normal capacity of the bladder is 400 to 600 millilitres (about 14 to 21 ounces).

CHEMOTHERAPY

Chemotherapy (or “chemo”) uses drugs to destroy cancer cells. In this sense, chemotherapy has the same effect as radiation therapy. Some chemotherapy drugs are given on their own or several chemotherapy drugs may be given together.

Certain chemotherapy drugs have been shown to make the cancer cells more responsive to radiation therapy. For this reason, radiation therapy and chemotherapy are often done together (called “concurrent” or “concomitant” therapy). In some cases, chemotherapy is given over several weeks before radiation treatments start (called “neoadjuvant”).

Combining radiation and chemotherapy offers you the best chance of killing the bladder cancer cells in your body.

Most chemotherapy drugs are put right into your bloodstream through “intravenous” or “IV treatment.” Each treatment can last from a few minutes to a few hours.

As with radiation therapy, chemotherapy can have side effects, which you should discuss with your doctor. Side effects vary widely and treatments are often available for any side effects that you may have.

RADIATION THERAPY

Radiation therapy uses high-energy radiation (most commonly x-rays) to shrink tumours and kill cancer cells. Radiation kills the cancer cells by damaging their DNA. Cancer cells whose DNA is damaged beyond repair stop dividing or die. When the damaged cells die, they are broken down and eliminated by the body’s natural processes.

While radiation therapy can also damage normal cells, your medical team will take potential damage to normal cells into account when planning a course of radiation therapy. Doctors know how much radiation normal tissue can safely receive. They use this information to help decide the extent and dosage of radiation.

In some cases, your radiation team may first implant a “fiducial marker” into the bladder. This is an object (or sometimes a special liquid) that is visible on scans of the bladder, and may help more accurately define and target the tumour site. This is called “image-guided” radiotherapy.

Radiation therapy is given in the hospital radiotherapy department as a series of short daily treatments. You can usually have it as an outpatient. Each treatment takes 10 to 15 minutes, and is usually given Monday through Friday, with a rest on the weekend. A course of radiotherapy for bladder cancer may last four to seven weeks.

You may have chemotherapy before or during the course of radiotherapy, or both, to help make the radiotherapy more effective.

External radiotherapy does not make you radioactive and it is perfectly safe for you to be with other people, including children, after each treatment session.

Side effects vary widely and your doctor will discuss them with you. Be sure to report any side effects that you may have to your doctor as soon as possible, as there are treatments that may help.

In the years following radiation therapy, patients need to be followed closely – both for the possibility of recurrence in the bladder that might require surgery, but also because a few patients might develop bladder or bowel complications because of the radiation.

TRANSURETHRAL RESECTION OF BLADDER TUMOR (TURBT)

When you’re having bladder preserving therapy, you may need a repeat TURBT to remove as much of the bladder tumour as possible before starting chemotherapy and radiation.

TURBTs may be repeated as treatment progresses to remove any additional tumours that have grown. These tumours are identified using “cystoscopies” (the process of inserting a tube through the urethra and using a small camera to see inside the bladder), which you likely have also had previously.

SIDE EFFECTS OF TREATMENTS

Side effects can occur with any type of medical treatment, but not everyone has them or experiences them in the same way. Although not pleasant, side effects have to be weighed against the benefit of reducing or eliminating your cancer.

CHEMOTHERAPY

Side effects of chemotherapy will depend on the type of drug used and the dose, how the drug is given and your overall health. They can happen any time during or after chemotherapy. Most side effects go away when chemotherapy is over, although some side effects may be longer-lasting or even permanent.

Some of the most common side effects of chemotherapy drugs are fatigue, nausea, changes to blood cell counts (increasing the risk of infection), loss of appetite, effects on bowel movements and urination, and hair loss. It’s important to let your medical team know of any side effects that you experience, because many of them can be treated. And, hair usually grows back after treatments have stopped.

RADIATION THERAPY

Some of the more common side effects of radiation therapy are fatigue; effects on urinary function, such as frequency, urgency, mild burning sensation while urinating; and effects on bowel movements. The side effects mostly go away after treatments end, but radiation may have some longer-term effects on bladder and bowel function.

Again, it’s important to discuss any side effects with your medical team, as they can suggest ways to ease them.