Bladder Cancer Treatment Options By Stage [I to IV]

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The bladder cancer treatment depends on the stage, grade, location, number, the performance status of the patient, along with other factors.

Following are the preferred treatment approaches for different stages of bladder cancer, but the final decision is taken after clinical assessment of the patient by an oncologist.

Ta N0 M0 (Stage 0a) – Transurethral resection with clear margins is considered preferred treatment approach. The patient may be given intravesical chemotherapy to prevent disease recurrence.

T1 N0 M0 (Stage I) – In case of low grade disease, transurethral resection with complete removal of all cancer cells followed by intravesical chemotherapy is considered as the first choice of treatment.
In case of high grade disease where transurethral resection cannot achieve complete removal of cancer cells, cystectomy (a partial or completed removal of the bladder) is considered as the preferred treatment approach.

T2 N0 M0 (Stage II) – When transurethral resection indicates muscle-invasive disease, radical cystectomy (see description) is considered as the standard treatment. Few patients may be treated with partial cystectomy (see description). Addition of chemotherapy before (preferred) or after surgery is recommended.
In patients who are not good candidates for cystectomy, radiotherapy with or without chemotherapy may be employed.

localised bladder cancer treatment infographic
T3-4a N0 M0
T1-4a N1M0 (Stage IIIa)

Radical cystectomy (see description) is considered as the standard treatment. Addition of chemotherapy before (preferred) or after surgery is recommended.
In patients who are not good candidates for cystectomy, radiotherapy with or without chemotherapy may be employed.

T1-4a N2-3 M0
T4b Any N M0 (Stage IIIb)

Chemotherapy with/without radiation therapy is the preferred initial treatment and the further decision is taken depending on the response to initial treatment.
locally advanced bladder cancer treatment

Any T Any N M1a (Stage IVa) – Chemotherapy with/without radiation therapy is the preferred initial treatment and the further decision is taken depending on the response to initial treatment.

Any T Any N M1b (Stage IVb) – Chemotherapy is the mainstay of treatment in case the disease has spread to distant body parts/organs.
Palliative therapy to relieve symptoms and improve the quality of life may be employed.

metastatic bladder cancer treatment

Following is the brief description of various options employed for colon cancer:

  1. Surgery: Surgery is the treatment of choice for muscle-invasive and some higher stage bladder cancers that have not spread to distant body parts and can be completely removed.

    Partial cystectomy can be performed, depending on location and number of tumor(s), which allows the patient to retain bladder function. However, a complete cystectomy is generally required for higher stage disease, wherein the entire bladder and nearby lymph nodes are generally removed.In radical cystectomy, prostate and seminal vesicles are also removed in men, while the ovaries, fallopian tubes, uterus, cervix, and a small portion of the vagina are often removed in women.

  2. Intravesical Therapy: In this technique, drug is placed directly into the bladder using a catheter. It can produce local action without affecting other body parts.

    Drugs like mitomycin, valrubicin, docetaxel, thiotepa, and gemcitabine can be given by this technique. Bacillus Calmette-Guerin (BCG) (a modified tuberculosis bacterium) can also be given by this technique, which acts by activating the body’s immune system to destroy cancer cells. The most common side effects associated with intravesical therapy is irritation/burning in the bladder.

  3. Chemotherapy: Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly growing cancer cells. It is considered to be the mainstay of treatment for advanced stage disease that has spread to distant body parts. Depending on the physician’s preference and patient’s condition, it may also be combined with other treatment options to accelerate the benefit achievement. It may be associated with side effects due to its effect on normal body cells apart from cancerous cells.
  4. Radiation Therapy: Radiation therapy (or radiotherapy) uses high-energy radiation directed to the affected area to kill cancerous cells. It can be employed either by using an external radiation source (external beam radiation therapy) or by directly placing the source of radiation near the cancer tissue (brachytherapy). It is commonly used in conjunction with chemotherapy for the treatment of advanced-stage bladder cancer to prevent recurrence. It may sometimes be used for palliation of symptoms such as pain, bleeding, etc.

It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Sometimes the patient’s choice and health condition are also important to make a treatment choice.

Following are ultimate goals of treating bladder cancer:

  • Prolongation of life
  • Reduction of symptoms
  • Improvement of overall quality of life

Treatment of Localised and Locally advanced bladder cancer

Video Transcript:

We will first discuss the treatment for Localised bladder cancer. In this technique, a hollow tube called a cystoscope which is fitted with a camera is inserted into the urethra and is slowly advanced into the bladder. It helps to confirm the presence of a bladder tumor and see its location, number, and extent. Also, it helps in transurethral resection of bladder tumor which is both diagnostic and therapeutic.

As you can see in this figure, only cancer containing superficial layers are removed, without damaging the deeper layers.

After TURBT, the histopathology reports tells us whether the tumor is non-muscle invasive or muscle invasive, i.e., whether it has infiltrated the muscle or not. We will first discuss the treatment for non-muscle invasive bladder tumors.

This is carcinoma in situ which is a flat tumor, limited to the epithelium.

Intravesical chemotherapy should be given in all cases of This disease. As you can see in the figure, in this procedure the chemotherapy drug is directly instilled into the bladder, with the help of a catheter.

And Ta is the papillary tumor which is limited to the epithelium.

For Ta disease also, intravesical chemotherapy may be given. But in some cases, intravesical chemotherapy may not be required, when we can keep the patient under observation.

When the tumor infiltrates into the lamina propria, it is called as T1.

For T1 disease, the treatment depends on whether the tumor is low grade or high grade. Intravesical chemotherapy is the treatment of choice for low-grade tumors. Whereas, for high-grade tumors, the preferred modality of treatment is cystectomy or surgical resection of the bladder.

When it infiltrates into the inner muscle layer, it is called as T2a. And T2b, when it infiltrates the outer muscle layer.

For a T2 disease with nodes negative, the preferred modality of treatment is chemotherapy followed by cystectomy. Usually, the cystectomy is radical cystectomy in which the whole bladder is removed. But in highly selected cases we can do partial cystectomy also. But for non-cystectomy candidates in which we are not planning for surgery, a combination of chemotherapy and radiation therapy may be used.

But the final decision whether to do surgery or not, or to do total or partial cystectomy will be taken by the oncologist, on an individual patient basis, depending upon the exact stage of the disease, number, and location of bladder tumors, and co-morbidities and performance status of the patient.

With this we come to the end of the treatment of localised bladder tumors, now let’s come to the treatment of locally advanced bladder tumors.

Till T2, the tumor is limited to the bladder wall. But when the tumor infiltrates through the bladder wall to involve the perivesical tissue, it is called T3.

And in T4 disease, the tumor infiltrates through the bladder wall to involve the adjacent structures. It may extend downwards to infiltrate prostate gland in males, as you can see in this figure.

Whereas in females, it may extend posteriorly to involve the uterus or vagina.

For T3 disease, and selected patients of T4 disease, as discussed above, with nodes negative, the preferred modality of treatment is cystectomy, with chemotherapy, which may be given before or after surgery. But for non-cystectomy candidates, in which we are not planning surgery, a combination of chemotherapy and radiotherapy may be used.

The tumor may also extend anterolaterally, to involve pelvic or abdominal wall.

This figure shows the pelvic and iliac group of lymph nodes, which are the regional nodes for a bladder. Depending upon the number and location of the nodes involved, it can be N1, N2 or N3.

In selected patients of T4 disease, with abdominal or pelvic wall extension, and any patient with the node-positive disease, the preferred modality of treatment is chemotherapy, with or without radiation therapy. And further therapy maybe decided to depend upon the response to initial treatment.

Treatment for Metastatic Bladder Cancer [Video]

Video Transcript:

Now let’s come to the treatment for metastatic bladder tumor. Distant metastasis from bladder cancer may occur to the bones.

Or to the liver in form of multiple nodular deposits.

It may also spread to one or both the lungs as seen in the figure.

Or to the peritoneum in form of multiple peritoneal deposits.

Chemotherapy or immunotherapy is the mainstay of treatment for metastatic disease. But other modalities like surgery, radiation therapy, or bone-directed therapy may be used for palliation or relief of symptoms.

Always remember that metastatic disease is not generally curative. So the intent of the treatment is a prolongation of life, reduction of symptoms, and improvement in the quality of life of the patient.

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