The bladder is a hollow pelvic organ that collects urine before it exits the body during urination. Because of this role, the bladder is an important element of the urinary tract. The kidneys, ureters, and urethra are also part of the urinary tract. The renal pelvis is a funnel-shaped portion of the kidney that collects urine and transports it to the ureter. The ureter is a tube that connects the kidneys to the bladder. The urethra is the tube that transports pee from the body. The urinary tract includes the prostate gland.
The bladder, like the rest of the urinary tract, is lined with a layer of cells known as the urothelium. A thin, fibrous band called the lamina propria separates this layer of cells from the bladder wall muscles, known as the muscularis propria.
BLADDER CANCER
Bladder cancer develops when healthy cells in the bladder lining, most commonly urothelial cells, mutate and expand uncontrollably, causing a tumor. The renal pelvis and ureters are likewise lined by urothelial cells. Cancer that develops in the renal pelvis and ureters is likewise classified as urothelial cancer and is commonly referred to as upper tract urothelial cancer. In most cases, it is treated similarly to bladder cancer, as detailed in this handbook. A tumor might be malignant or noncancerous. A malignant tumor is one that can grow and spread to other regions of the body. A benign tumor is one that can develop but does not spread. Benign bladder tumors are quite uncommon.
BLADDER CANCER TYPES
The type of bladder cancer is determined by the appearance of the tumor’s cells under a microscope. The three primary kinds of bladder cancer are as follows:
Urothelial carcinoma: Urothelial carcinoma (UCC) accounts for over 90% of all bladder cancers. It also accounts for 10% to 15% of all kidney cancers identified in adulthood. It starts in the urinary tract’s urothelial cells. Transitional cell carcinoma, or TCC, is another name for urothelial cancer.
Squamous call carcinoma: Squamous cells form in the bladder lining as a result of irritation and inflammation. These cells have the potential to become cancerous over time. Squamous cell carcinoma makes for about 4% of all bladder cancers.
Adenocarcinoma: This kind, which arises from glandular cells, accounts for around 2% of all bladder cancers.
Other, less prevalent kinds of bladder cancer include, among others, sarcoma of the bladder and small cell bladder cancer. Bladder sarcomas frequently develop in the bladder’s fat or muscular layers. Small cell bladder cancer is a rare form of bladder cancer that has the potential to spread to other parts of the body.
SYMPTOMS OF BLADDER CANCER
1. Urine contains blood or blood clots.
2. During urinating, you may experience pain or a burning sensation.
3. Urination is frequent.
4. Feeling the desire to urinate several times during the night.
5. Feeling the need to urinate but being unable to do so.
6. One side of the body is experiencing lower back ache.
Most bladder cancers are discovered after a person complains to their doctor about blood in their urine, also known as hematuria. The term “gross hematuria” refers to the presence of enough blood in the urine for the patient to notice it. It’s also possible that there’s some blood in the pee that you can’t see. This is known as “microscopic hematuria,” and it can only be detected by a urine test.
Because hematuria can be an indication of various other illnesses other than cancer, such as an infection or kidney stones, general urine tests are not utilized to make a definitive diagnosis of bladder cancer. Cytology, a test in which the urine is examined under a microscope to look for cancer cells, is one sort of urine test that can determine whether or not there is cancer.
When the first signs of bladder cancer occur, the cancer may have already spread to other parts of the body. The symptoms in this case are determined by where the cancer has progressed. Cancer that has migrated to the lungs, for example, may produce a cough or shortness of breath; cancer that has gone to the liver may cause abdominal discomfort or jaundice (yellowing of the skin and whites of the eyes); and cancer that has spread to the bone may cause bone pain or a fracture (broken bone). Other signs of advanced bladder cancer include back or pelvic pain, unexplained appetite loss, and weight loss.
Please consult your doctor if you are concerned about any changes you are experiencing. In addition to other questions, your doctor will inquire as to how long and how frequently you have been experiencing the symptom(s). This is done to assist in determining the cause of the condition, which is referred to as a diagnostic.
If cancer is discovered, symptom relief is an important element of cancer care and treatment. This is known as palliative care or supportive care. It is frequently initiated shortly after diagnosis and continues throughout treatment. Talk to your health care team about any symptoms you are experiencing, especially any new or changing symptoms.
STAGES AND GRADES OF BLADDER CANCER
Staging describes where the cancer is located, whether or not it has invaded or spread, and whether or not it is impacting other sections of the body.
Doctors utilize diagnostic tests to determine the stage of cancer, therefore staging may not be complete until all of the tests are completed. Knowing the stage assists the doctor in determining the best course of treatment and can help estimate a patient’s prognosis, or possibility of recovery. Distinct forms of cancer have different stage descriptions.
The stage of bladder cancer is diagnosed by evaluating the sample retrieved during a TURBT and determining if the cancer has spread to other regions of the body.
TNM system of staging
The TNM system is one technique that clinicians use to describe the stage. Doctors use diagnostic test and scan results to address the following questions:
- Tumor(T): What is the size of the main tumor? Where can I find it?
- Node(N): Has the cancer spread to your lymph nodes? If so, where are they and how many are there?
- Metastasis(M): Is the cancer in other parts of the body? If so, where and how much has it spread?
The results are aggregated to establish each person’s cancer stage. There are five stages: stage 0 (zero), stages I through IV, and level V. (1 through 4). The stage provides a common language for doctors to describe the cancer so that they can collaborate to determine the best treatments.
Clinical and pathological staging are both possible. Clinical staging is determined by the results of pre-surgery diagnostics, which may include a history, physical examinations, imaging scans, and biopsies. Pathological staging is determined by what is discovered after surgery (such as the removal of the entire bladder), as well as the results of physical examinations, imaging scans, and biopsies. Pathological staging, in general, provides the health care provider with the greatest information to establish a prognosis.
More information on each component of the TNM system for bladder cancer can be found below:
Tumor (T)
The “T” plus a letter and/or number (0 to 4) is used in the TNM system to describe the size and location of the tumor. Stages can also be subdivided into smaller groups to assist describe the tumor in greater detail. If more than one tumor is present, the lowercase letter “m” (many) is appended to the “T” stage category. If the “T” stage begins with a lowercase “c,” the tumor was clinically staged. If it begins with a lowercase “p,” it indicates that the tumor was pathologically staged. If a patient’s tumor is removed, the stage of the tumor is listed below.
Bladder cancer
TX: The primary cancer cannot be evaluated.
T0: There is no evidence of a primary bladder tumor.
Ta: Noninvasive papillary carcinoma is referred to as this. This type of tumor is frequently discovered on a little portion of tissue that is easily removed with a TURBT.
Tis: This stage is referred to as carcinoma in situ (CIS) or a “flat tumor.” This signifies that the cancer is exclusively located on or near the bladder’s surface. Non-muscle-invasive bladder cancer, superficial bladder cancer, or noninvasive flat carcinoma are all terms used by doctors to describe this type of malignancy. This kind of bladder cancer frequently recurs after therapy, generally as another benign bladder cancer.
T1: The tumor has expanded to the connective tissue (known as the lamina propria) that divides the bladder lining from the muscles beneath, but it has not migrated to the bladder wall muscle.
T2: The tumor has migrated to the bladder wall muscle.
- T2a: The tumor has progressed to the inner half of the bladder wall muscle, also known as the superficial muscle.
- T2b: The tumor has progressed to the bladder’s deep muscle (the outer half of the muscle).
T3: The tumor has spread to the perivirial tissue (the fatty tissue that surrounds the bladder).
- T3a: As seen through a microscope, the tumor has expanded into the perivesical tissue.
- T3b: The tumor has expanded macroscopically into the perivesical tissue. This signifies that the tumor(s) is/are large enough to be seen or touched by the doctor during imaging testing.
T4: The tumor has spread to the abdominal wall, pelvic wall, a man’s prostate or seminal vesicle (the tubes that deliver sperm), or a woman’s uterus or vagina.
- T4a: The tumor has metastasized to the prostate, seminal vesicles, uterus, or vagina. At this time, surgical excision of the tumor may still be possible.
- T4b: The tumor has progressed to either the pelvic or abdominal wall. At this stage, surgical excision of the tumor may be impossible.
T4: The tumor has spread to the abdominal wall, pelvic wall, a man’s prostate or seminal vesicle (the tubes that deliver sperm), or a woman’s uterus or vagina.
- T4a: The tumor has metastasized to the prostate, seminal vesicles, uterus, or vagina. At this time, surgical excision of the tumor may still be possible.
- T4b: The tumor has progressed to either the pelvic or abdominal wall. At this stage, surgical excision of the tumor may be impossible.
Renal pelvis and ureter
TX: The primary cancer cannot be evaluated.
T0: There are no signs of a primary tumor in the renal pelvis or ureter.
Ta: Noninvasive papillary carcinoma is referred to as this. This sort of tumor is frequently detected on a small area of tissue that is easily eliminated by endoscopic resection.
Tis: This stage is referred to as carcinoma in situ (CIS) or a “flat tumor.”
T1: The cancer has spread to connective tissue underlying the lining of the renal pelvis or ureter.
T2: The tumor has progressed to the muscle layer.
T3: The tumor has spread into the peripelvic fat (fat layers surrounding the kidney), the renal parenchyma (the part of the kidney that filters blood and produces urine), or the fat surrounding the ureter.
T4: The tumor has progressed to surrounding organs or into the kidney’s outer layer of fat.
Node (N)
The letter “N” in the TNM staging system denotes lymph nodes. These little, bean-shaped organs aid in the battle against infection. Regional lymph nodes are lymph nodes located near the site of the malignancy, within the real pelvis (named hypogastric, obturator, iliac, perivesical, pelvic, sacral, and presacral lymph nodes). Lymph nodes located in other sections of the body are referred to as distant lymph nodes.
Bladder cancer
NX: The lymph nodes in the region cannot be evaluated.
N0: The cancer has not spread to the lymph nodes in the surrounding area.
N1: The cancer has progressed to one regional lymph node in the pelvic region.
N2: The cancer has progressed to two or more pelvic regional lymph nodes.
N3: The cancer has migrated to the common iliac lymph nodes, which are positioned above the bladder behind the major arteries in the pelvis.
Renal pelvis and ureter
NX: The lymph nodes in the region cannot be evaluated.
N0: The cancer has not spread to the lymph nodes in the surrounding area.
N1: In a single lymph node, the cancer is 2 centimeters (cm) or smaller.
N2: The cancer has progressed to more than one lymph node or is greater than 2 cm in a single lymph node.
Metastasis (M)
The letter “M” in the TNM system indicates if the cancer has moved to other parts of the body, a condition known as distant metastasis.
M0: The disease has not spread.
M1: There has been distant metastasis.
- M1a: The cancer has only progressed to lymph nodes outside the pelvic.
- M1b: Other regions of the body have been affected by the cancer.
Renal pelvis and ureter
M0: The sickness has not spread.
M1: A distant metastasis has occurred.
Cancer stage grouping
The bladder cancer stage is determined by combining the T, N, and M classifications.
Bladder cancer
Stage 0a: This is a very early cancer that only affects the surface of the bladder’s inner lining. Cancer cells congregate and are frequently easily eliminated. The cancer has not spread to the bladder wall’s muscle or connective tissue. Noninvasive papillary urothelial carcinoma is another name for this form of bladder cancer (Ta, N0, M0).
Stage 0is: This type of cancer, also known as a flat tumor or carcinoma in situ (CIS), only affects the bladder’s inner lining. It has not extended to the bladder’s thick layer of muscle or connective tissue, nor has it grown into the hollow region of the bladder (Tis, N0, M0). This is always a high-grade malignancy (see “Grades” below) and a dangerous disease since it can develop to muscle-invasive disease.
Stage I: The malignancy has spread through the bladder’s inner lining and into the lamina propria. It hasn’t gone to the thick layer of muscle in the bladder wall, nor has it moved to lymph nodes or other organs (T1, N0, M0).
Stage II: The cancer has spread into the bladder’s strong muscular wall. It’s sometimes referred to as invasive cancer or muscle-invasive cancer. The tumor has not migrated to the lymph nodes or other organs and has not reached the fatty tissue around the bladder (T2, N0, M0).
Stage III: The cancer has spread through the muscular wall to the fatty layer of tissue around the bladder (perivesical tissue) or to the prostate in men or the uterus and vagina in women. Alternatively, the cancer has progressed to the lymph nodes in the surrounding area.
- Stage IIIA: The tumor has spread to the perivesical tissue or the prostate, uterus, or vagina but not to the lymph nodes or other organs (T3a, T3b, or T4a; N0; M0), or the cancer has spread to a single regional lymph node (T1 to T4a, N1, M0).
- Stage IIIB: The malignancy has progressed to at least two regional lymph nodes or the common iliac lymph nodes (T1 to T4a, N2 or N3, M0).
Stage IV: The tumor has spread into the pelvic or abdominal wall, or the cancer has migrated to lymph nodes outside the pelvis or other parts of the body.
Stage IVA: The tumor has spread to the pelvic or abdominal wall but not to the rest of the body (T4b, any N, M0), or the cancer has spread to lymph nodes outside the pelvis (any T, any N, M1a).
Stage IVB: the cancer has spread to other regions of the body (any T, any N, M1b).
Renal pelvis and ureter
Stage 0a: This is a very early stage of cancer that only affects the surface of the inner lining of the renal pelvis or ureter. Cancer cells congregate and are frequently easily eliminated. Noninvasive papillary carcinoma is another name for this form of cancer (Ta, N0, M0).
Stage 0is: This type of cancer, also known as a flat tumor or carcinoma in situ (CIS), only affects the inner lining of the renal pelvis or ureter (Tis, N0, M0).
Stage I: The cancer has spread to the lining of the renal pelvis or ureter. The cancer has not progressed to the lymph nodes or any other organs (T1, N0, M0).
Stage II: The cancer has spread to the muscle that lies behind the inner lining of the renal pelvis or ureter. The cancer has not progressed to the lymph nodes or any other organs (T2, N0, M0).
Stage III: The cancer has spread beyond the muscle and into the fat surrounding the kidney or ureter, as well as into the renal parenchyma. The cancer has not progressed to the lymph nodes or any other organs (T3, N0, M0).
Stage IV: The tumor has spread to surrounding organs or the kidney’s outer layer of fat (T4, NX or N0, M0), or the cancer has spread to the lymph nodes (any T, N1 or N2, M0), or there is distant metastasis (any T, any N, M1).
Recurrent cancer
Cancer that recurs after therapy is referred to as recurrent cancer. If the cancer returns, more tests will be performed to determine the degree of the recurrence. These tests and scans are frequently identical to those performed at the time of the first diagnosis.
Grade (G)
Doctors also classify this sort of cancer based on its grade (G). When viewed under a microscope, the grade describes how much cancer cells resemble healthy cells.
The malignant tissue is compared to healthy tissue by the doctor. In healthy tissue, numerous different types of cells are clustered together. If the cancer resembles healthy tissue and contains distinct cell groupings, it is referred to as “differentiated” or a “low-grade tumor.” When malignant tissue differs significantly from healthy tissue, it is referred to as “poorly differentiated” or a “high-grade tumor.”
Many urologic surgeons rate tumors based on the likelihood that the disease will recur or develop and spread, a process known as progression. They frequently organize treatment based on grade, employing the following categories:
- Low grade: This form of cancer has a chance of recurring.
- High grade: This form of cancer has a higher recurrence and growth rate.
DIAGNOSIS OF BLADDER CANCER
Many tests are used by doctors to detect or diagnose cancer. They also perform tests to see whether the cancer has spread to another place of the body from where it began. This is referred as as metastasis. Imaging tests, for example, can reveal whether or not the cancer has spread. Images of the inside of the body are produced via imaging tests. Doctors may also conduct tests to determine which treatments are most likely to be effective.
A biopsy is the only guaranteed way for a doctor to know if a part of the body has cancer in most cases of cancer. During a biopsy, the doctor extracts a small sample of tissue for laboratory testing. If a biopsy is not possible, the doctor may recommend alternative tests to aid in the diagnosis.
This section discusses the many methods for diagnosing bladder cancer. Not all of the tests described below will be administered to every individual. When selecting a diagnostic test, your doctor may take the following variables into account:
1. The cancer type suspected
2. Your symptoms and signs
3. Your age and general well-being
4. The outcomes of previous medical tests
The sooner bladder cancer is detected, the better the chances of successful treatment and cure. However, because there is no test that is accurate enough to screen the general population for bladder cancer, most patients are diagnosed with the disease after they develop symptoms. As a result, when the cancer is discovered, some persons have more advanced (later stage) disease. Nonetheless, most people are diagnosed with benign bladder cancer.
The following tests may be used to diagnose bladder cancer and learn more about it:
- Urine test: A urine cytology test can be conducted if your doctor discovers any quantity of blood in your pee. Urine cytology frequently employs a random urine sample from regular urination to determine whether or not the urine includes malignancy cells. If a patient is having a cystoscopy (see below), an extra test that involves washing the bladder and collecting the liquid through the cystoscope or another small tube placed into the urethra may be conducted. A variety of methods can be used to test the sample. The most frequent method is to examine the cells under a microscope, which is known as urine cytology. Other pee tests based on molecular analysis can be performed to aid in the detection of cancer, usually along with urinary cytology.
- Biopsy/Transurethral resection of bladder tumor (TURBT): A biopsy will be performed if abnormal tissue is discovered after a cystoscopy. A biopsy is the removal of a small sample of tissue for microscopic examination. A transurethral bladder tumor resection, or TURBT, is the name given to this surgical operation.
- The tumor and a sample of the bladder muscle near the tumor are removed during a TURBT. Based on the results of the cystoscopy, the doctor may decide to do further biopsies of different regions of the bladder. Another technique that is frequently performed prior to a TURBT is termed EUA (exam under anesthesia). During this treatment, the urologist examines the bladder to determine whether any masses can be felt. A pathologist examines any tissue samples obtained during the TURBT. A pathologist is a medical professional who specializes in interpreting laboratory tests and assessing cells, tissues, and organs to identify disease.
- A TURBT is used to diagnose bladder cancer and determine the type of tumor, the depth to which it has grown into the bladder layers, and the presence of any additional microscopic malignant alterations, known as carcinoma in situ (CIS). A TURBT can also be utilized to treat non-muscle-invasive tumors.
- Cystoscopy: Cystoscopy is the primary method of diagnosing bladder cancer. It enables the doctor to see into the body using a cystoscope, which is a narrow, illuminated, flexible tube. Flexible cystoscopy is conducted in a doctor’s office and does not require anesthesia, which is a pain-blocking medicine. This quick procedure can detect bladder growths and determine whether a biopsy or surgery is required.
The imaging tests listed below may be used to determine if bladder cancer has spread and to aid in staging:
- Computed tomography (CT) scan: A CT scan uses x-rays captured from various angles to create images of the inside of the body. A computer merges these images to create a detailed, three-dimensional image that reveals anomalies or tumors. A CT scan can be performed to determine the size of the tumor as well as identify enlarged lymph nodes, which may suggest that the disease has spread. To improve image detail, a specific dye known as a contrast medium is sometimes administered before to the scan. This dye can be injected directly into a patient’s vein (intravenous) or given to them as a beverage to drink. Patients should inform the professionals doing this test if they are allergic to iodine or other contrast media before undergoing this test. Because the intravenous contrast dye used in a CT scan might cause kidney difficulties, patients who have any form of kidney condition should notify the personnel before the scan.
- Positron emission tomography (PET) or PET-CT scan: A PET scan is frequently coupled with a CT scan (see above), resulting in a PET-CT scan. However, your doctor may refer to this technique simply as a PET scan. A PET scan is a technique for creating images of organs and tissues within the body. A radioactive chemical is put into the patient’s body in a modest amount. This chemical is absorbed by the cells that consume the most energy. Cancer absorbs more radioactive stuff because it aggressively uses energy. The material is then detected by a scanner, which produces images of the inside of the body.
- In some cases, ongoing research suggests that a PET scan may be able to detect bladder cancer that has spread more effectively than a CT scan or MRI alone. Despite this, PET scans are not considered routine imaging for bladder cancer and are rarely used in this condition.
- Magnetic resonance imagery (MRI): An MRI produces detailed images of the body by using magnetic fields rather than x-rays. MRI can be used to determine the size of a tumor as well as identify enlarged lymph nodes, which may signal that cancer has spread. To provide a crisper image, a special dye known as a contrast medium is administered before to the scan. This dye is distinct from the one used for CT scans (see above) and can be injected into a patient’s vein.
- Ultrasound: An ultrasound creates a picture of the interior organs by using sound waves. It can assist in determining whether the kidneys or ureters are obstructed. This test does not necessitate the use of any form of contrast material.
After the diagnostic tests are completed, your doctor will go through the results with you. If cancer is the diagnosis, these data will also assist the clinician in describing the cancer. This is referred to as staging and grading.
BLADDER CANCER TREATMENTS
The following are brief summaries of the most frequent types of bladder cancer therapies. Take the time to read about all of your treatment options, and don’t be afraid to ask clarifying questions. Also, discuss the aims of each treatment with your doctor, as well as what you might expect while undergoing the treatment. These discussions are known as “shared decision making.” When you and your doctors collaborate to choose therapies that meet the goals of your care, this is referred to as shared decision making. Because there are various treatment choices for bladder cancer, shared decision making is especially crucial.
Surgery
During an operation, the tumor and some healthy tissue surrounding it are removed. There are several methods of surgery for bladder cancer. Based on the stage and severity of the condition, your health care provider will propose a specific procedure.
Transurethral bladder tumor resection (TURBT): This method is used for diagnosis, staging, and treatment. During TURBT, a surgeon inserts a cystoscope into the bladder through the urethra. The tumor is then removed by the surgeon utilizing a tool with a thin wire loop, a laser, or fulguration (high-energy electricity). Before the procedure, the patient is given an anesthetic, which is a pain-blocking medicine.
TURBT may be able to remove bladder cancer in persons with non-muscle-invasive malignancy. However, the doctor may offer additional therapies, such as intravesical chemotherapy or immunotherapy, to reduce the likelihood of the disease returning (see below). Additional therapies, such as bladder removal surgery or, less typically, radiation therapy, are usually advised for persons with muscle-invasive bladder cancer. Chemotherapy is frequently utilized in the treatment of muscle-invasive bladder cancer.
Urinary diversion: If the bladder is removed, the doctor will devise a new method of removing pee from the body. One method is to route urine via a piece of the small intestine or colon to a stoma or ostomy (an orifice) on the outside of the body. To collect and drain urine, the patient must wear a bag linked to the stoma.
Surgeons can occasionally utilize a section of the small or large intestine to create a urinary reservoir, which is a storage pouch that sits inside the body. A urine bag is not required for these treatments. For certain patients, the surgeon is able to attach the pouch to the urethra, forming a neobladder, allowing the patient to flow pee outside of the body. If the neobladder is not completely empty, the patient may need to implant a thin tube called a catheter. In addition, individuals with a neobladder will no longer feel the urge to urinate and will need to learn to urinate on a regular timetable.
Other patients have an internal (inside the abdomen) pouch made of tiny intestine that is attached to the skin of the abdomen or belly button (umbilicus) via a small stoma (an example is an “Indiana Pouch”). Patients do not need to wear a bag using this procedure. Patients drain the internal pouch several times per day by inserting a catheter through the tiny stoma and removing the catheter promptly.
Radical cystectomy and lymph node dissection: A radical cystectomy involves the removal of the whole bladder as well as any adjacent tissues and organs. For men, the prostate and a portion of the urethra are routinely removed as well. The uterus, fallopian tubes, ovaries, and a portion of the vagina may be removed in women. Lymph nodes in the pelvis are excised in all patients. This is referred to as a pelvic lymph node dissection. The most precise method for detecting cancer that has progressed to the lymph nodes is an extensive pelvic lymph node dissection. In rare, extremely specific cases, it may be necessary to remove only a portion of the bladder, a procedure known as partial cystectomy. This operation, however, is not the standard of therapy for those suffering from muscle-invasive illness.
Instead of the single bigger incision used in traditional open surgery, the physician makes numerous small incisions or cuts during a laparoscopic or robotic cystectomy. The bladder is subsequently removed by the surgeon using telescopic tools with or without robotic assistance. To remove the bladder and surrounding tissue, the surgeon must make an incision. This type of operation necessitates the use of a surgeon with extensive competence in this field. Your doctor can go over these choices with you and assist you in making an informed selection.
Bladder cancer surgery side effects
Living without a bladder might have a negative impact on a patient’s quality of life. An essential therapy goal is to find strategies to keep all or part of the bladder. Some persons with muscle-invasive bladder cancer may benefit from treatment options that include chemotherapy and radiation therapy after optimum TURBT (see “Bladder Preservation” under Treatments by Stage).
The method determines the side effects of bladder cancer surgery. According to research, having a surgeon with bladder cancer experience can enhance the result of persons with bladder cancer. Patients should have in-depth discussions with their doctors to understand exactly what side effects may occur, including urinary and sexual side effects, and how they can be treated. In general, the following adverse effects may occur:
- Damage to pelvic nerves and loss of sexual sensitivity and orgasm in both men and women. These issues may be resolved with additional treatment.
- Risks associated with anesthesia or other concurrent medical conditions.
- For a period of time, you may experience a loss of stamina or physical strength.
- Prolonged recovery time
- Infection
- Bleeding or blood clots
- Discomfort following surgery, as well as harm to surrounding organs
- Infections or urine leaks following a cystectomy or urinary diversion. When a neobladder is implanted, the patient may be unable to urinate or completely empty the bladder.
- After a cystectomy, the inability of a penis to become erect, known as erectile dysfunction. A nerve-sparing cystectomy can be performed on occasion. Men may be able to have a normal erection if this is done correctly.
Discuss the potential side effects of the specific surgery you will undergo with your health care provider prior to surgery.
Chemotherapy
Chemotherapy is the use of medications to eradicate cancer cells, typically by preventing the cancer cells from growing, dividing, and proliferating. A chemotherapy regimen, or schedule, typically consists of a predetermined number of cycles administered over a predetermined time period. A patient may be administered one medicine at a time or a mixture of drugs on the same day.
To treat bladder cancer, two forms of chemotherapy may be utilized. The type recommended by the doctor and when it is administered are determined by the stage of the malignancy. Patients should discuss chemotherapy with their doctor before or after surgery.
Intravesical chemotherapy: A urologist is usually the one who administers intravenous, or local, chemotherapy. Drugs are given into the bladder via a catheter put through the urethra during this type of therapy. Local treatment only kills cancer cells that come into touch with the chemotherapy solution. It is unable to target bladder wall tumor cells or tumor cells that have migrated to other organs. The most often used medications for intravesical chemotherapy are mitomycin-C (a generic drug), gemcitabine (Gemzar), docetaxel (Taxotere), and valrubicin (Valstar). Mitomycin (Jelmyto) was also approved by the FDA in 2020 for the treatment of low-grade upper tract urothelial carcinoma.
Systemic chemotherapy: The following are the most popular systemic, or whole-body, chemotherapy regimens used to treat bladder cancer:
- Cisplatin and gemcitabine
- Carboplatin (a generic medication) and gemcitabine
- MVAC is a four-drug combination that includes methotrexate (Rheumatrex, Trexall), vinblastine (Velban), doxorubicin, and cisplatin.
- Dose-dense (DD)-MVAC with growth factor support: This is the same regimen as MVAC, but the period between treatments is shorter, and it has mostly supplanted MVAC.
- Paclitaxel or docetaxel (available as a generic drug)
- Pemetrexed (Alimta)
Many systemic chemotherapies are still being studied in clinical studies to determine which medications or drug combinations work best to treat bladder cancer. A combination of medications is usually more effective than a single drug. The use of cisplatin-based chemotherapy before major surgery for muscle-invasive bladder cancer is firmly supported by evidence. This is referred to as “neoadjuvant chemotherapy.”
If platinum-based chemotherapy shrinks or slows/stabilizes advanced or metastatic urothelial cancer, immunotherapy with avelumab (Bavencio, see below) may be used to try to prevent or delay cancer recurrence and help people live longer lives. This is referred to as switch maintenance treatment.
Chemotherapy side effects vary depending on the medicine, combination regimen, and dose utilized, but they might include exhaustion, infection risk, blood clots and bleeding, loss of appetite, taste changes, nausea and vomiting, hair loss, and diarrhea, among other things. These adverse effects normally fade away once the treatment is completed.
Targeted therapy
Targeted therapy is a type of cancer treatment that targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This method of treatment inhibits the growth and spread of cancer cells while attempting to minimize damage to healthy cells.
The targets of all cancers are not the same. Your doctor may order genomic testing to determine the genes, proteins, and other variables in your tumor in order to find the most effective treatment. This enables clinicians to better match each patient with the most effective standard treatment and, when possible, appropriate clinical trials. Furthermore, research studies are continuing to learn more about specific molecular targets and new treatments aimed at them.
Erdafitinib (Balversa): Erdafitinib is an orally administered medicine licensed to treat persons with locally advanced or metastatic urothelial carcinoma with FGFR3 or FGFR2 genetic alterations that has grown or spread during or after platinum treatment. There is a unique FDA-approved companion test to determine who may benefit from erdafitinib medication.
Common erdafitinib side effects include elevated phosphate levels, mouth sores, weariness, nausea, diarrhea, dry mouth/skin, nails detaching from the nail bed or poor nail growth, and changes in appetite and taste. Erdafitinib may also cause rare but serious eye problems including as retinopathy and epithelial detachment, which may result in blind areas known as visual field deficits. An ophthalmologist or optometrist evaluation is required at least in the first four months, along with frequent Amsler grid assessments at home.
Enfortumab vedotin-ejfv (Padcev): Enfortumab vedotin-ejfv is licensed for the treatment of locally advanced (unresectable) or metastatic urothelial carcinoma in the following patients:
- People who have previously undergone a PD-L1 immune checkpoint inhibitor plus platinum chemotherapy (see “Immunotherapy” above).
- People who are unable to receive cisplatin chemotherapy because they have already received one or more treatments
Enfortumab vedotin-ejfv is an antibody-drug combination that targets the urothelial cancer protein Nectin-4. Antibody-drug conjugates bind to cancer cell targets and then release a little amount of cancer medicine into the tumor cells. Fatigue, peripheral neuropathy, rash, hair loss, changes in appetite and taste, nausea, diarrhea, dry eye, itching, dry skin, and increased blood sugar are all common side effects of enfortumab vedotin-ejfv.
Sacituzumab govitecan: Sacituzumab govitecan is licensed to treat patients with locally advanced or metastatic urothelial carcinoma who have previously been treated with platinum chemotherapy and a PD-1 or PD-L1 immune checkpoint inhibitor, which includes many people with urothelial carcinoma. Sacituzumab govitecan, like enfortumab vedotin-ejfv, is an antibody-drug conjugate, but it has a significantly different structure, components, and mode of action. Some of the most common adverse effects of sacituzumab govitecan include a low count of specific white blood cells (neutropenia), nausea, diarrhea, fatigue, hair loss, anemia, vomiting, constipation, decreased appetite, rash, stomach pain, and a few others.
Discuss with your doctor the potential side effects of a certain medicine and how to manage them.
Immunotherapy
Immunotherapy, also known as biologic therapy, is intended to increase the body’s natural defenses against cancer. It employs components created by the body or in a laboratory to enhance, target, or restore immune system activity. It can be administered locally or systemically.
Local therapy
Bacillus Calmette-Guerin (BCG): BCG, a weakened mycobacterium identical to the bacteria that causes tuberculosis, is the standard immunotherapy medication for bladder cancer. BCG is injected directly into the bladder via a catheter. This is known as intravesical treatment. BCG binds to the bladder lining and activates the immune system to eliminate tumor cells. BCG can produce flu-like symptoms, fevers, chills, weariness, a burning feeling in the bladder, and bladder hemorrhage, among other things.
Interferon (Roferon-A, Intron A, Alferon): Interferon is another form of immunotherapy that is rarely used as an intravenous treatment. It is occasionally used with BCG if BCG alone does not help treat the cancer, but it is extremely rare anymore.
Systemic therapy
Immune checkpoint inhibitors: One important field of immunotherapy research is the development of medications that inhibit the protein PD-1 or its ligand, PD-L1. PD-1 is present on the surface of T cells, a type of white blood cell that aids the body’s immune system in fighting disease. Because PD-1 prevents the immune system from eliminating cancer cells, inhibiting its function permits the immune system to more effectively remove cancer.
Atezolizumzab (Tecentriq): The drug atezolizumab is a PD-L1 inhibitor. It can be used to treat advanced urothelial cancer in persons who are unable to receive cisplatin-based chemotherapy because their tumors overexpress PD-L1. People in the United States who are unable to receive platinum-based chemotherapy can also get atezolizumab, regardless of whether their tumors overexpress PD-L1.
Avelumab (Bavenicio): If chemotherapy has delayed or decreased advanced urothelial carcinoma, the PD-L1 inhibitor avelumab can be given after chemotherapy, regardless of whether the tumor expresses PD-L1, because it has been found to prolong life and reduce the chance of cancer progressing. Switch maintenance therapy is the name given to this type of treatment. Avelumab is also used to treat advanced or metastatic urothelial carcinoma that has not responded to platinum treatment.
Nivolumab (Opdivo): Nivolumab is a PD-1 inhibitor used to treat advanced or metastatic urothelial carcinoma that has not responded to platinum treatment. It may also be given after complete surgical removal of the cancer, known as adjuvant therapy, to reduce the likelihood of recurrence in those who are at high risk of recurrence due to cancer stage.
Pembrolizumab (Keytruda): In some cases, pembrolizumab, a PD-1 inhibitor, can be used to treat bladder cancer.
1. Platinum treatment has not halted advanced or metastatic urothelial cancer. It is the only immunotherapy proven to help people in this scenario live longer lives (compared to taxane or vinflunine chemotherapy).
2. Non-muscle-invasive bladder cancer (Tis) that has not been halted by BCG treatment in persons who cannot or do not wish to have a radical cystectomy.
3. Advanced urothelial cancer in persons who are unable to receive cisplatin-based chemotherapy because their tumors overexpress PD-L1.
4. People who are unable to receive platinum-based chemotherapy in the United States can get pembrolizumab regardless of whether their tumors overexpress PD-L1.
Immune checkpoint inhibitors are still being explored in clinical studies for all stages of bladder cancer.
Different forms of immunotherapy might result in a variety of adverse effects. Fatigue, skin reactions (such as itching and rash), flu-like symptoms, thyroid gland function abnormalities, hormonal and/or weight fluctuations, diarrhea, and lung, liver, and gut inflammation are all common adverse effects. Any organ in the body can be a target of an overactive immune system, so chat with your doctor about the potential side effects of the immunotherapy you’ve been prescribed so you know what to look for and can report any changes to your health care team as soon as possible.
Radiation therapy
The use of high-energy x-rays or other particles to eliminate cancer cells is known as radiation therapy. A radiation oncologist is a doctor who specializes in the use of radiation therapy to treat cancer. External-beam radiation therapy, which is radiation therapy delivered from a machine outside the body, is the most prevalent method of radiation treatment. Internal radiation therapy, often known as brachytherapy, is the use of implants to deliver radiation therapy. Brachytherapy, on the other hand, is not employed in bladder cancer. A radiation therapy regimen, or schedule, typically consists of a predetermined number of treatments administered over a predetermined time period.
Radiation therapy is rarely used alone as a primary treatment for bladder cancer, however it is frequently used in conjunction with systemic chemotherapy. Some persons who are unable to take chemotherapy may be treated solely with radiation treatment. To treat cancer that is solely found in the bladder, a combination of radiation therapy and chemotherapy may be used:
- When appropriate, to eliminate any cancer cells that may remain following optimum TURBT, so that all or portion of the bladder does not have to be removed.
- To alleviate tumor-related symptoms such as pain, bleeding, or obstruction.
Radiation therapy might cause fatigue, moderate skin responses, and loose bowel motions. Side effects from bladder cancer are most common in the pelvic or abdominal area and may include bladder irritation, the need to pass urine often during therapy, and bleeding from the bladder or rectum; other side effects may occur less frequently. Most adverse effects subside quickly after treatment is completed.
REMISSION AND THE POSSIBILITY OF RECURRENCE
When cancer cannot be identified in the body and there are no symptoms, the patient is said to be in remission. This is often known as having “no evidence of illness,” or NED.
Remission can be either temporary or permanent. Many people are concerned that the cancer will recur as a result of this uncertainty. While many remissions are durable, it is vital to discuss the potential of the cancer returning with your doctor. Understanding your recurrence risk and treatment options may make you feel more prepared if the cancer returns.
Recurrent cancer occurs when the cancer returns after the initial treatment. It may return in the same location (called a local recurrence), nearby (called a regional recurrence), or elsewhere (distant recurrence, also known as metastasis).
When this happens, a fresh round of testing begins to discover as much as possible about the recurrence. Following the completion of this testing, you and your doctor will discuss treatment choices.
Non-muscle-invasive bladder cancers that recur in the same area as the original tumor or elsewhere in the bladder may be treated in the same way as the original cancer. If the cancer returns after treatment, a radical cystectomy may be recommended. Bladder cancers that reoccur outside the bladder are more difficult to treat surgically and are frequently treated with systemic medicine, radiation therapy, or both. Your doctor may also propose that you participate in clinical studies that are researching new ways to treat this sort of recurring cancer. Palliative care might be beneficial for alleviating symptoms and side effects regardless of the treatment approach you pick.
People suffering from recurring cancer frequently experience emotions such as bewilderment or anxiety. You are urged to discuss these feelings with your health care provider and inquire about support options to assist you in coping.
