In the United States, bladder cancer is one of the most common cancers of the urinary tract. Like any cancer, catching it early—before it has spread outside of the bladder—is important for survival.
“Bladder cancer is divided into two categories: muscle-invasive bladder cancer and non-muscle invasive bladder cancer,” says Johar Raza, M.D., a urologic oncologist at Henry Ford Health. “Non-muscle invasive bladder cancer means the tumor has remained inside the inner lining of the bladder. Muscle-invasive bladder cancer means it has spread into a muscle that’s located deep inside the bladder wall. Once it has spread to this muscle, the tumor is likely to spread to other parts of the body.
“I often use this analogy: when a stranger is walking in front of your house, you keep an eye on them through the window. But if they try to break in, you call 911. So for non-muscle invasive bladder cancer, we keep an eye on things. We will get rid of the tumor but we won’t rush to big treatment options. But once the disease is muscle invasive, we’ll go for the most aggressive treatment options.”
What Are The Treatment Options For Bladder Cancer?
There are a variety of treatments for bladder cancer, from standard-of-care options to newer treatments that are proving to be very effective.
Standard-of-care treatment options for bladder cancer
- Surgery. If your bladder cancer is non-invasive, surgery consists of “scraping off” the tumor and leaving the rest of the bladder intact. If your cancer is invasive, surgery to remove the bladder is required. “At the same time as bladder removal surgery, we’ll perform reconstructive surgery to create a new bladder or a new pathway to restore urinary function,” says Dr. Raza.
- Chemotherapy. Chemotherapy is usually coupled with surgery. Within the past few years, receiving chemotherapy before surgery has become important. “If someone receives chemotherapy before surgery, the tumor can downstage and shrink,” says Dr. Raza. “If we do surgery on a downstage tumor, the survival rate is higher. We can’t predict which patients will respond well to chemotherapy, but I think it’s worth it to get chemotherapy before surgery.”
- Radiation therapy. Radiation is often used with chemotherapy to help it work better. Clinical trials are currently trying to determine if coupling radiation with chemotherapy can control the growth of the tumor so that the bladder doesn't have to be removed.
New treatment options for bladder cancer
- Immunotherapy. Immunotherapy trains your immune system to destroy cancer cells. It's being studied as an alternative to chemotherapy, before and after removing the bladder. "Immunotherapy is less toxic than chemotherapy, so there are fewer side effects," says Dr. Raza. "And some immunotherapy drugs may be able to control the disease better if residual cancer cells are left behind after surgery. A newer trial recently showed that patients who received immunotherapy before surgery had a very significant improvement in survival compared to what we've traditionally seen with getting chemotherapy before surgery."
- Enfortumab vedotin-pembrolizumab (EVP). This treatment combines immunotherapy with something called an antibody-drug conjugate. "EVP basically binds to tumor cell receptors and increases penetration into the tumor cells to more effectively destroy them," says Dr. Raza. "EVP can kill cancer cells a lot better than standard chemotherapy. For patients with muscle-invasive bladder cancer, it has been shown to improve survival by about 50% one year later. Another benefit of it is that patients can receive this drug even if they can't receive standard-of-care chemotherapy because of heart or kidney issues, for example."
- Circulating tumor DNA test. This is a blood test that can eradicate the need for unnecessary treatment. "Circulating tumor DNA are tiny fragments of the tumor that can be detected through a simple blood test," says Dr. Raza. "Historically, after surgery and an initial round of treatment, we often put patients on one year of maintenance treatment. But if this blood test comes back negative - meaning they don't have residual tumor cells circulating in their blood - then they won't have to undergo additional treatment." Another benefit of this test, Dr. Raza adds, is that this blood test will show a positive result sooner than you'd find anything in a CT scan.
Methods Of Bladder Reconstruction
As bladder removal is a standard treatment option, you might be wondering what is used to replace your bladder. There are a couple of options. Talk to your doctor about which one is best for you. They include:
Bladder Cancer Care at Henry Ford Health
- Conduit. This procedure uses a part of the small intestine to create a tube from the ureters (the ducts that let urine pass from the kidney to the bladder) to the abdomen. Urine then flows through this tube into a urine bag worn outside of your body. “This allows you to continue bowel movements in a normal way,” says Dr. Raza. “While you have to empty the bag every so often, it usually stays camouflaged by your clothes.”
- Reservoir. “We use part of the small intestine to create a pouch inside the body that connects from the ureters to the abdomen,” says Dr. Raza. This pouch collects urine and a catheter is inserted at skin level to drain the urine. This option is only used in select cases, though, since you have to be vigilant about draining the urine.
- Neobladder. The neobladder procedure is perhaps the most innovative option. “We use part of the small intestine to create a new bladder, which we connect to the ureters and the urethra (the tube that passes urine out of the body) to allow urination,” says Dr. Raza. “This process of taking urine away is somewhat natural—very natural compared to the conduit and reservoir. I’ve been performing these surgeries with the help of a robot. Traditionally, open neobladder surgery requires a longer skin incision and lot of stitches. But with the robot, surgery involves a smaller incision, less blood loss, faster healing time and less complications. Some surgeons prefer to do the conduits, because it is easy to perform on the surgeon’s part and easier to manage by the patients. (For example, you have to learn to pass urine through abdominal pressing and perform exercises to hold urine for better continence.) But we offer robotic neobladder to all eligible patients at Henry Ford.”
Reviewed by Johar Raza, M.D., a urologic oncologist at Henry Ford Health. He sees patients at Henry Ford Cancer—Detroit, Henry Ford Hospital, Henry Ford West Bloomfield Hospital and Henry Ford Medical Center—Fairlane.
