Bladder Cancer

Treatment

Treatment for bladder cancer depends on the stage of the disease, the type of cancer, and the patient's age and overall health. It generally begins within a few weeks after the diagnosis. The treatment options for bladder cancer are surgery, radiation therapy, chemotherapy and biological therapy. Sometimes  a combination of these therapies are used.

Surgery
It is the most common and widely used treatment for bladder cancer.  It is used for all types and stages of bladder cancer.  Depending on the stage and grade of the tumor, the surgery include :

Transurethral resection: Also called TUR, this method is used to treat superficial bladder cancer (carcinoma in situ). An instrument called resectoscope is inserted through the urethra and into the bladder. A small wire loop on the end of the instrument removes the tumor by cutting it or burning it with electrical current. This is called fulguration. After TUR, patients may also have chemotherapy or biological therapy.

Radical cystectomy :  Radical cystectomy is the removal of the entire bladder as well as its surrounding lymph nodes and other structures that may contain cancer. This major surgery is used for cancers that have invaded through the bladder wall or for superficial cancers that extend a large part of the bladder. Not only the entire bladder but also other structures are removed.

Segmental or partial cystectomy: The procedure of removing only a part of the bladder is called segmental cystectomy. It is usually performed for treating low-grade cancer that have invaded the bladder wall but are limited to a small area of the bladder.

Side Effects : After surgery, the patients may have some blood in their urine and difficulty or pain when urinating. Radical cystectomy may affect a person's sexual function. This surgery stops the production of semen because it removes the prostate and seminal vesicles in men. And in women the womb (uterus), ovaries, and part of the vagina are removed. As a result, menopause may occur and most women are not able to get pregnant.

Bladder reconstruction
The bladder is completely removed in radical cystectomy. Removal of the bladder required an ostomy (surgical creation of an artificial opening) and an external bag to collect urine. This is called urinary diversion. The continent urinary reservoir or catheterizable stoma, the neobladder, urinary or ileal conduit are some procedure include in bladder reconstruction.

In continent urinary reservoir, a piece of the colon (large intestine) is used to form an internal pouch capable of holding three or four cups of urine. The urine cane be drained from the pouch with a catheter several times a day and the stoma site is easily concealed by a band aid. 

In neobladder procedure, the surgeon literally recreates a bladder. The process involves suturing a similar intestinal pouch used in a catheterizable stoma to the urethra. As a result, the urine can eliminate without having an external opening. This is a complex reconstruction procedure and may lead to various complications such as scarring, internal urine leakage and incontinence.

Radiation therapy
It is also called radiotherapy and uses high-energy rays to kill cancer cells. It affects cancer cells only in the treated area. Radiation may be given for small-muscle invasive bladder cancers. Some patients may have radiation therapy before surgery to shrink the tumor and others may have it after surgery to kill cancer cells that may remain in the area. The two types of radiation therapy used to treat bladder cancer are :

Internal radiation : A small pellet of a radioactive substance is placed inside the bladder through the urethra or by making a tiny incision in the lower abdominal wall. During the entire treatment, the patient must stay in the hospital. When the treatment is done, the pellet is removed. Once it is removed, no radioactivity is left in the body.

Side Effects : With external radiation, healthy tissue overlying or adjacent to the tumor can be damaged. The side effects of radiation depend on the dose and the area of the body where the radiation is targeted. Internal organs, bones, and other tissues can also be damaged. Common effects include extreme tiredness, vomiting, increased susceptibility to infections, hair loss, easy bruising or bleeding. Radiation therapy may cause decrease in the number of white blood cells. External radiation may permanently darken the skin in the treated area. Radiation to the pelvis may also cause nausea, diarrhea, urinary problems, and sexual problems such as vaginal dryness in women and erectile dysfunction in men.

Chemotherapy
Chemotherapy is a systemic treatment using anti-cancer drugs to destroy cancer cells throughout the body. It is given alone or combined with surgery, radiation therapy or both. Depending on the stage of bladder cancer, chemotherapy can be classified into intravesical (within the bladder) and intravenous (within a blood vessel). 

Intravesical chemotherapy is given for patients with superficial bladder cancer. After removing the cancer, a thin, flexible tube called a catheter, is inserted into the bladder through the urethra. One or more liquid drugs are introduced into the bladder through this tube. The drugs remain in the bladder for several hours and they affect the cancer cells in the bladder. It is then drained out with urination. Usually this treatment is done once a week for several weeks. 

If the cancer has deeply invaded the bladder or spread to lymph nodes or other organs, the cancer-fighting drugs are injected into the bloodstream via a vein. This is called systemic or intravenous chemotherapy. The drugs given flows through the bloodstream to almost every part of the body and kill cancer cells wherever they are. The drugs are usually given in cycles so that a recovery period follows every treatment period.

Side Effects : Side effects of chemotherapy vary from patient to patient and it depends mainly on the drugs and doses received, as well as how the drugs are given. Intravesical chemotherapy can irritate the bladder or kidneys. They may cause a rash when they come into contact with the skin or genitals. Common side effects of intravenous chemotherapy include nausea, vomiting, hair loss, loss of appetite, feeling tired or lacking energy, tingling in the fingers, ringing in the ears, increased susceptibility to infection, easy bruising or bleeding and mouth sores. Most side effects disappear when treatment ends.

Biological Therapy
Biological therapy or immunotherapy uses the body's natural ability to fight cancer and helps to prevent the cancer from coming back. One widely used type of immunotherapy is intravesical BCG treatment. It is mainly for superficial bladder cancer. BCG solution contains live, weakened bacteria that activate the immune system to kill cancer cells in the bladder. BCG solution is introduced into the bladder through a thin catheter that has been passed through the urethra. The Mycobacterium in the fluid stimulates the immune system to produce cancer-fighting substances. The solution is held in the bladder for a few hours and then drained out. This treatment is usually done once a week for 6 weeks and repeated at various times over several months or even longer in some cases.

Side Effects : BCG therapy may irritate the bladder and cause minor bleeding in the bladder. Patients may feel tired and have painful urination. Other side effects include nausea, low-grade fever, and chills.

Recently developed treatments for bladder cancer include : 

Interferons
These naturally occurring compounds are directly inserted into the bladder through a catheter to slow the growth of tumors.
Side Effects include bladder infections, blood in the urine, and signs and symptoms similar to those of the flu. In some cases, interferons have developed serious lung or liver infections.

Photodynamic therapy (PDT)
PDT is a new treatment that uses special drugs and light to kill cancer cells. In this therapy, a chemical called photofrin is put into the bladder and makes cancer cells more sensitive to light. When cells are exposed to light from a laser, they are killed or damaged.
Side Effects : PDT may produce serious side effects, such as chronic bladder infections, bladder shrinkage and long-term sensitivity to sunlight.

After Treatment

Bladder cancer has an unusually high propensity for recurring after treatment, so follow-up care is very important. It may reoccur . Urine cytology and cystoscopy are performed every 3 months for 2 years, every 6 months for the next 2 years, and then yearly.

Regular follow up ensures early detection and treatment. If the bladder was not removed, the doctor will perform cystoscopy and remove any new superficial tumors that are found. Patients also may have urine tests to check for signs of cancer. Follow up care may also include blood tests, x-rays, or other tests. Drinking plenty of fluids may dilute any cancer-causing substances in the bladder and may help flush them out before they can cause damage.