Bladder Cancer Treatment
At MD Anderson, you receive personalized bladder cancer care from some of the nation¡¯s leading specialists. A team including urologic surgeons, medical oncologists and radiation oncologists work together to plan your treatment and recovery.
Your bladder cancer care is customized to incorporate the most advanced therapies, including:
- Advanced surgical and reconstructive procedures, including robotic surgery and robotic reconstructive surgery.
- Advanced cancer drugs, including antibody drug conjugates and targeted therapies.
- Radiation techniques designed to deliver high doses of radiation to the tumor while sparing healthy tissue.
Our skilled surgeons, who utilize the latest bladder cancer and reconstruction techniques, are among the most experienced in the nation. This can make an essential difference in the success of your treatment and recovery.
And, as one of the nation¡¯s largest cancer research centers, we offer a variety of clinical trials for new therapies for bladder cancer.
If you are diagnosed with bladder cancer, your doctor will discuss the best options to treat it. This depends on several factors, including the type and stage of the cancer and your general health.
Your treatment for bladder cancer at MD Anderson will be customized to your particular needs. One or more of the following therapies may be recommended to treat the cancer or help relieve symptoms.
Bladder cancer treatment plans
For patients whose bladder cancer has not spread to distant parts of the body, treatment will generally include surgery. If this cancer is in its early stages and has not moved into to the muscle wall, patients may receive intravesical therapy (washing the inside of the bladder with immunotherapy or chemotherapy drugs).
For patients whose disease has spread into the bladder's muscle wall, there are two main treatment options. One is surgery to remove the bladder. These patients may receive chemotherapy before surgery to shrink the tumor.
The other is a combination of three treatments designed to let patients keep their bladder: Transurethral resection, which involves scraping cancer cells from the inner surface of the bladder, followed by chemotherapy and radiation therapy. This treatment is an option for selected patients, often those with smaller tumors. It is also used for patients who are not good candidates for surgery.
Patients whose cancer has spread beyond the bladder to distant sites like the lungs, liver or bones, usually get chemotherapy, immunotherapy, or targeted therapy. These patients may also be eligible for clinical trials.
Bladder cancer treatments
Bladder cancer surgery
Surgery is part of almost every bladder cancer patient¡¯s treatment. It is often offered with other types of treatment given before or after the procedure.
In many cases, MD Anderson surgeons operate on bladder cancer patients with minimally invasive techniques, such as robotic cystectomy and robotic reconstruction procedures. These may offer shorter hospital stays, less blood loss and faster recovery times.
There are two primary types of bladder cancer surgery:
Transurethral resection (TUR) involves scraping the tumor from the bladder wall. It can be used to retrieve suspected cancer cells for a diagnosis and to help treat bladder cancer. The procedure is done with a resectoscope, a thin tool with a wire loop on the end that is placed through the urethra and into the bladder. TUR can be used on its own for superficial bladder cancer. It can also be used in combination with chemotherapy and radiation therapy for cancers that have moved into the bladder¡¯s muscle wall.
Cystectomy, or removal of the bladder, is often used in more advanced bladder cancer. Usually the entire bladder is removed, but a few patients are candidates for a partial cystectomy. Lymph nodes near the bladder will also be removed. In men, the prostate also is usually removed. In women, the uterus, ovaries, fallopian tubes and often a small part of the vagina may need to be removed, though many times this is not required.
Bladder reconstruction surgery
When the bladder is removed to treat bladder cancer, surgical procedures known as urinary diversions are performed to give the body a way to store and remove urine. Urinary diversions are done at the same time as a cystectomy. There are three common types of urinary diversion:
Ileal conduit: This is the most common urinary diversion. A piece of the small intestine is used to create a ¡°pipe¡± that connects the ureters to the surface of the skin. This opening, called a stoma, is usually located a few inches to the right of the bellybutton. Urine is continuously drained into a urostomy bag connected to the stoma and worn on the outside of the body. It is a simple and efficient procedure, but some patients may have issues with wearing an external bag.
Ileal neobladder: Part of the ileum (small intestine) is used to make a new bladder, allowing for urination through the urethra. This procedure is more common for men than women. For most patients, it provides good daytime urinary control, with about a 20% chance of nighttime incontinence. Patients who get an ileal neobladder may need occasional catheterization. This need is slightly more common in women than men.
Continent reservoir: Intestinal tissue is used to create an internal pouch that is connected to the navel or a nearby spot. The patient uses a catheter to drain the pouch every three to four hours. This type of reconstruction can avoid a stoma when a neobladder is not feasible or recommended.
Chemotherapy
Chemotherapy drugs kill cancer cells, control their growth or relieve disease-related symptoms. Chemotherapy may involve a single drug or a combination of two or more drugs, depending on the type of cancer and how fast it is growing.
Chemotherapy can be used with surgery when bladder cancer has a high risk of metastasis. Bladder tumors that have invaded the muscle wall and have the potential to spread can benefit from chemotherapy before surgery.
Doctors are studying new chemotherapy treatments for treating advanced bladder cancer.
Learn more about chemotherapy.
Antibody Drug Conjugates
Antibody drug conjugates link cancer fighting drugs like chemotherapy with antibodies designed in a lab to recognize cancer cells. This combination delivers powerful doses of medication while limiting negative side effects.
Antibody drug conjugates are currently approved only for patients with metastatic bladder cancer. Research is underway to expand their use to other patients.
Immune checkpoint inhibitors
Immune checkpoint inhibitors are a type of immunotherapy. They stop the immune system from turning off before cancer is completely eliminated.
For bladder cancer, immune checkpoint inhibitors are currently used only for stage IV cancer. Clinical trials are underway to study the use of these drugs in other settings.
Learn more about immune checkpoint inhibitors.
Targeted therapy
Targeted therapy drugs are designed to stop or slow the growth or spread of cancer. This happens on a cellular level. Cancer cells need specific molecules (often in the form of proteins) to survive, multiply and spread. These molecules are usually made by the genes that cause cancer, as well as the cells themselves. Targeted therapies are designed to interfere with, or target, these molecules or the cancer-causing genes that create them.
Targeted therapy is currently only approved to treat stage IV cancers with specific genetic mutations.
Learn more about targeted therapy.
Radiation therapy
Radiation therapy uses powerful, focused beams of energy to kill cancer cells. There are several different radiation therapy techniques. Doctors can use these to accurately target a tumor while minimizing damage to healthy tissue.
The types of radiation used to treat bladder cancer include:
- Intensity modulated radiation therapy (IMRT), which focuses multiple radiation beams of different intensities directly on the tumor for the highest possible dose.
- Volumetric modulated arc therapy, a form of IMRT that utilizes a rotating treatment machine to deliver radiation at multiple angles.
For bladder cancer patients, radiation therapy is used in combination with chemotherapy and transurethral resection surgery.
Learn more about radiation therapy.
Intravesical therapy
Superficial bladder cancer has a high rate of recurrence. Intravesical therapy can help decrease the risk of tumor recurrence and progression (tumor growing deeper into bladder wall). First, the bladder wall is scraped to remove any superficial tumor cells. After the patient has recovered from surgery, doctors use a catheter to fill the bladder with a medication to destroy any remaining cancer cells and prevent recurrence. The medication may be Bacillus Calmette-Gu¨¦rin (BCG), an immunotherapy that stimulates the patient¡¯s immune system to destroy cancer cells, or a chemotherapy drug.
Gene therapy
Gene therapy modifies a patient's DNA to fight cancer. These therapies can insert a healthy copy of a gene into a cell, remove or replace parts of an abnormal gene, inhibit the growth of cancer cells and prevent the production of disease cells.
For bladder cancer, gene therapy is used to treat patients whose disease has not spread into the muscle walls but does not respond to intravesical therapy.
Bladder cancer clinical trials
Clinical trials are a key component of MD Anderson's mission to end cancer. MD Anderson uses clinical trials to find better ways to prevent, diagnose and treat cancer.
Clinical trials for bladder cancer include expanding the use of immunotherapy, targeted therapy and antibody drug conjugates, as well as combinations of these and other treatments.
Your doctor may offer you a clinical trial as a treatment option.
Learn more about clinical trials.
In rare cases, bladder cancer can be passed down from one generation to the next. Genetic counseling may be right for you. Visit our genetic testing page to learn more.
Learn more about bladder cancer:
What is a total pelvic exenteration?
¡°Exenteration¡± refers to a complex surgery in which organs, bones and other structures are removed from the pelvis in order to treat cancer. A pelvic exenteration might involve the bladder, rectum, anus and/or sacrum (tailbone), as well as the prostate gland in men and the vagina and/or uterus in women.??
While this procedure may sound fairly extreme, it is often the best ¡ª and only potentially curative ¡ª option for some types of cancer. It also provides the best possible chance of long-term cancer control.?
But which cancers does a pelvic exenteration typically treat? What makes you a good candidate for one? How will it affect your sex life and bathroom habits? And, what else should you know about this life-changing operation? Read on for answers.?
Which cancers is a total pelvic exenteration used most frequently to treat?
A total pelvic exenteration (TPE) is most commonly used for locally advanced rectal cancer?or another type of cancer that involves the rectum. This is because of the way cancer grows and spreads in the rectum. But TPE is also used to treat:?
In fact, pelvic exenteration was originally designed to treat recurrent cervical cancer. It originated as an operation for this gynecologic cancer because the cervix is located in the center of the pelvis. In the days before HPV vaccinations prevented most cervical cancers and radiation therapy was used to treat it, cervical cancer often grew into the structures around it. This procedure was seen as a way of clearing it out.?
Are there different types of exenterations?
An exenteration used to treat rectal cancer usually involves the removal of the rectum, plus something else. That could be the bladder, the bone behind the rectum (the sacrum), or any of the other structures surrounding it that are not normally removed during rectal surgery. Generally speaking, though, there are three types of exenterations:
Anterior exenteration
In a male, this entails removing the bladder and the prostate, but leaving the rectum intact. In a female, this involves removing the bladder, uterus and possibly the vagina, but leaving the rectum intact.??
Posterior exenteration
This involves the removal of the rectum and sacrum, as well as the uterus (if present) and possibly part of the vagina in a female.?
Total pelvic exenteration
In a male, this involves removal of the rectum, bladder and prostate. In a female, this normally entails the removal of the rectum, bladder and uterus (if present) and can also include the vagina.?
Which patients make the best candidates for an exenteration?
Ideally, we want you to be at your very fittest before an exenteration. That way, you¡¯ll have some strength in reserve if any complications arise. So, any therapies we might recommend before that are all part of a plan to get your body prepared for surgery, not to help you avoid it.??
Your best chance for a cure is when we can do a TPE early as a planned part of your treatment, rather than waiting to do it as a last resort when systemic treatments are no longer working. But a TPE is a long and very complex operation, and the recovery can be prolonged. Not all patients will be able to undergo it. So, the first thing we ask is, ¡°Do you have a cancer that¡¯s resectable?¡± That is: ¡°Can your tumor be removed with surgery? Then, your surgeon will determine if you are fit enough to undergo it.??
Unfortunately, a lot of patients are told elsewhere that this type of surgery is impossible, even when their cancer is not metastatic and is still potentially curable. They only come to MD Anderson after other treatments have failed. Other patients are so leery of the procedure itself that they¡¯ll try almost anything to avoid it.?
The trouble is that while chemotherapy and radiation therapy can sometimes slow a cancer¡¯s growth, the problems caused by a locally advanced tumor in the pelvis often become worse. These can include severe pain, obstructions, infections, blood supply problems, and nerve damage. All of those may end up becoming much bigger issues than they would¡¯ve been if someone had gotten the surgery earlier.?
Urothelial carcinoma: 8 insights about this common bladder cancer
Urothelial carcinoma is cancer that develops in the urothelial cells. These cells are located in the urothelium, which lines the inside of the urinary tract. Urothelial carcinoma can develop in the upper urinary tract (renal pelvis, ureter) or the lower urinary tract (bladder, urethra).
Most bladder cancers are urothelial carcinomas. We spoke with genitourinary medical oncologist , to learn more about urothelial carcinoma of the bladder, including symptoms, treatment and prognosis.
What causes urothelial carcinoma?
While we don¡¯t always know exactly what causes urothelial carcinoma, some factors can increase your chances of getting it.
Smoking or the use of tobacco products is one of the main risk factors. Cigarettes and other tobacco products contain carcinogens that get absorbed into the bloodstream and filtered by the kidneys. These harmful chemicals then collect in the urine, where they can cause cancer in the lining of the urinary tract.
Other risk factors include:
- Workplace exposure to certain chemicals, such as aromatic amines, which can be found in dyes, as well as oil refining, iron, steel, textile and rubber industries
- Chronic inflammation of the bladder, such as recurrent urinary tract infections or bladder catheters
- Exposure to other chemicals, such as arsenic in drinking water
- Prior chemotherapy, such as cyclophosphamide
- Prior radiation therapy, such as radiation to the prostate
- Genetic conditions, such as Lynch syndrome
Is urothelial carcinoma aggressive?
Muscle-invasive urothelial carcinoma can be aggressive. This is when the cancer has spread to the muscle walls of the bladder.
The cancer grade also determines if it¡¯s aggressive. The grade is based on the characteristics of the cancer cell viewed under a microscope. The pathologist who reviews the biopsy sample will look at how abnormal the cell looks compared to a normal cell. If it¡¯s a little bit abnormal and has some resemblance to normal cells, that¡¯s considered low-grade. If the cell looks very abnormal to the point where it¡¯s hard to tell if it looks like a normal cell at all, we consider it high-grade. High-grade urothelial carcinoma is a more aggressive form of cancer that tends to spread.
What are the symptoms of urothelial carcinoma?
The most common symptom is blood in the urine, also known as hematuria. It can be either something you can see with your eyes, or it might only show up during a urinalysis.
Other symptoms of urothelial carcinoma can include frequent urination and painful urination. These are also symptoms of urinary tract infections. We¡¯ve seen many patients who were treated by their primary care doctor for recurring UTIs when they actually had early-stage bladder cancer.
Waking up frequently at night to urinate is another symptom of urothelial carcinoma. This symptom is almost always associated with one or more other symptoms.
How is urothelial carcinoma diagnosed?
Doctors may use the following tests and procedures to diagnose urothelial carcinoma:
Urine tests/urinalysis
This checks for blood and other substances in your urine.
Cystoscopy
A thin tube with a lens (cystoscope) is inserted through the urethra into the bladder, allowing the urologist to examine the area for abnormalities. This exam can be done in the clinic or in the operating room if a transurethral resection is needed.
Transurethral resection
A thin tool with a wire loop on the end (resectoscope) is placed through the urethra into the bladder to collect tissue samples to biopsy. This procedure may be done during a cystoscopy.
CT urogram
This is a CT scan of the urinary tract in which an iodine dye is injected into the vein so that doctors can check for disease.
MRI
This imaging scan may be used in patients who cannot get a CT urogram because they are allergic to iodine or have low kidney function.
What are the treatment options for urothelial carcinoma?
Urothelial carcinoma can be treated in many ways. At MD Anderson, you will meet with a medical oncologist, urologic surgeon and sometimes a radiation oncologist during your first appointment. This team will help come up with the best treatment plan for you.
Your treatment plan will depend on several factors, including the cancer grade and stage, the location of the tumor and your general health. Your treatment may include:
- Surgery
- Chemotherapy
- Immunotherapy
- Targeted therapy
- Intravesical therapy
- Radiation therapy
Intravesical therapy can be used to inject chemotherapy or immunotherapy like Bacillus Calmette¨CGu¨¦rin (BCG) directly into the bladder. This type of therapy is usually only effective when the disease is in its earliest stages and has not spread beyond the bladder wall or invaded the muscle.
When a patient has muscle-invasive bladder cancer, we may not be able to preserve the bladder. When that happens, the patient may have a cystectomy. This is a surgery to remove the entire bladder.?
At MD Anderson, we customize treatment recommendations for every patient. For example, we may find it best to treat one patient with chemotherapy followed by a cystectomy; and for another patient, we may recommend radiation and chemotherapy with no surgery.??
Does urothelial carcinoma have a high risk for recurrence?
Urothelial carcinoma has a relatively high risk for systemic recurrence, which is recurrence outside of the urinary tract, that increases with a higher disease stage.
The risk for systemic recurrence in stage 0 (carcinoma in situ) or stage I urothelial carcinoma of the bladder is relatively low. However, the risk becomes higher when the cancer doesn¡¯t respond to intravesical BCG treatment. We usually estimate a 20% chance of cancer recurring outside of the bladder if you have early-stage disease.
Stage II urothelial carcinoma is muscle-invasive. Cancer at this stage has up to a 50% chance of relapse. Patients with stage II disease typically receive chemotherapy or other systemic therapies to reduce their chances of recurrence.
Stage III urothelial carcinoma occurs when cancer spreads to the fatty layers outside of the bladder or the lymph nodes. These patients have up to a 70% chance of relapse.???
Stage IV cancer is typically not curable, but it is treatable. More than 90% of patients with stage IV urothelial carcinoma will always have the disease.
What is the survival rate for urothelial carcinoma?
The outlook for patients with urothelial carcinoma depends on many factors, including:
- whether the cancer is muscle-invasive,
- if the cancer comes back and
- the patient¡¯s overall health
Your prognosis depends on how well the tumor responds to treatment, and it can change throughout the course of your treatment. It¡¯s important to talk to your doctor about your prognosis. Keep in mind that any survival rates your doctor shares are estimates and not based on your specific case.
What research is being done to advance urothelial carcinoma treatment?
There have been many discoveries and advances in urothelial carcinoma treatment in the past several years. These include Food and Drug Administration (FDA) approvals for new immunotherapy drugs nivolumab and pembrolizumab, a targeted therapy pill called erdafitinib that can be used in about 20% of patients who have FGFR3 genetic mutations, and antibody drug conjugates, such as enfortumab vedotin and sacituzumab govetican. Most recently, the FDA approved combinations of these therapies to treat bladder cancer, such as chemotherapy with immunotherapy and antibody drug conjugates with immunotherapy.
Urothelial carcinoma is a tough disease, but the field is rapidly evolving. In the future, we hope to develop more targeted therapies as we discover more genetic mutations, such as MTAP loss, HER2 amplification and many others. We¡¯re conducting clinical trials to develop new and better treatment options, and we¡¯re excited about what¡¯s to come.?
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