Bladder cancer is any neoplasm that arises or occurs in the urinary bladder of the body and is the most commonly occurring neoplasm of the urinary system. Urothelial carcinoma is the most commonly prevalent histological type of bladder carcinoma with nearly 90% of the patients attributed to this histological type.
As per the WHO, bladder cancer is the 10th most common cancer type across the world with over 600,000 cases reported annually and over 200,000 fatalities reported every year. Bladder cancer starts to develop when cells that make up the urinary bladder start to divide and proliferate out of control.
These cells start to grow out of control when the DNA inside the normal cells start to exhibit certain genetic and molecular changes. The DNA in our cells control how our cells function and any changes in this DNA can result in the body developing cancer.
Treatments For Bladder Cancer
In general the lines of treatment that are available for bladder cancer are –
- Surgery
- Chemotherapy
- Radiation Therapy
- Immunotherapy
- Targeted Therapy
In cancer a team of oncologists work together to develop a treatment plan that incorporates different lines of treatment. Treatment options and recommendations depend on different factors which include the type, the stage and the grade of the cancer. Some other factors that dictate treatment are the patients preferences and overall health and the possible side effects associated with each line of treatment.
The first line of treatment that a patient receives for urothelial cancer is referred to as the first-line therapy. If the first-line therapy doesn’t bring substantial benefits then the patient receives the second-line therapy. In some situations, third-line therapy may also be available. It is imperative that patients talk about the risks and benefits of all the possible treatment options so that they can form a well informed decision.
Bladder Cancer Treatment For Stages 0 and 1
Patients who have been diagnosed with low grade non-invasive bladder cancer (stage 0a) are treated with transurethral resection of bladder tumor (TURBT) first. TURBT is a surgical procedure that uses an instrument inserted into the patient’s urethra, ensuring that the abdomen is not cut up.
During this procedure the patient is either offered general anesthesia or regional anesthesia. A thin and rigid cytoscope called the rectoscope is inserted into the patient’s urethra and this rectoscope contains a wire loop at its end to remove any abnormal tissue or tumor. The removed tissue is then sent to a lab for testing. After the tissue or tumor has been removed, further steps are taken to ensure that the cancer has been completely destroyed.
The process of fulguration is conducted after this stage wherein the tissue in the area where the tissue was may be burned while examining it with the help of a rectoscope. Along with this the remaining cancer cells may be destroyed with the aid of a high energy laser, through the rectoscope.
Stage 0a
For low-grade (slow-growing) non invasive papillary tumors, intravesical chemotherapy is administered a few weeks after the surgery. If the cancer comes back, the same treatments may be repeated over the next year, to ensure that there is not a chance of recurrence. High-grade non-invasive tumors are more prone to coming back after treatment, due to this intravesical BCG is often recommended after surgery. Before this procedure, TURBT is repeatedly administered to ensure the viability of this procedure. BCG is usually started a few weeks after surgery has been conducted and is continued for multiple weeks.
Intravesical BCG is usually preferable to intravesical chemotherapy for high grade cancers. It can limit the possibility of a recurrence and prevents an existing cancer from getting worse. Stage 0 cancers usually require highly extensive surgeries. Partial or complete cystectomy (removal of the bladder) are taken into consideration when there are many superficial cancers or when cancer continues to grow despite treatment.
Stage 1
Stage 1 bladder cancer has grown into the connective layer of the bladder wall (T1) but has not reached the muscle layer. TURBT with fulguration is usually recommended as the first line of treatment for this stage of cancer. Although its primary focus is to determine the extent of the cancer and not to treat it. If no such treatment is administered then this will result in the formation of a new tumor that will be more advanced in stages. Such a situation is more likely to arise when the first cancer is more high grade.
If a cancer is low grade, a second TURBT procedure is recommended. If the doctors come to consensus that your tumor has been removed, intravesical BCG or even intravesical chemo may be offered. If all of the cancer is not removed then intravesical BCG may be offered. If the cancer is high grade and if the tumor is larger than when first it was discovered. Radical cystectomy may be recommended.
Since, radical cystectomy can be a disorienting experience and is not the most safest option for patients with poor overall health, radiation along with chemo may be recommended in such a scenario. .
Stage 2
Stage 2 cancers can be understood as cancers that have invaded the muscle layer of the bladder wall (T2a and T2b) but no farther. TURBT is conducted as the first line of treatment but is primarily conducted to determine the extent and stage of the cancer rather than try to cure it. When the cancer has invaded the muscle wall, radical cystectomy may be offered. If cancer is only one part of the bladder, a partial cystectomy may be done instead although this is only possible in a small number of patients. Radical cystectomy may be the only suitable line of treatment for patients with poor overall health as chemo would not be conducive for such patients. Although, it is seen in many cases that doctors will recommend chemotherapy before surgery since it has shown various benefits such as extending a patient’s expected duration of living with the disease. When chemotherapy is administered first, surgery is delayed and while this is not a problem when chemo shrinks the bladder, it can be deemed to be harmful if the size of the tumor continues to grow even while chemotherapy is offered.
Certain individuals may be offered a second and more substantial TURBT which is then followed by radiation and chemotherapy. Although if this is the line of treatment and protocol followed then frequent and careful follow up exams are conducted to ascertain the overall health of the patient.
Stage 3
Stage 3 cancers have reached the outside of the bladder (T3) and might have grown into nearby tissues or organs (T4) or the lymph nodes of the body but have not spread to the distant parts of the body. TURBT is again the first line of treatment and again is conducted to ascertain how far the cancer has spread into the body. Chemotherapy followed by radical cystectomy is then the standard line of treatment. Partial cystectomy is rarely used as an option in these types of cancers. Chemotherapy (before surgery) with or without radiation is also often administered to shrink the size of the tumor which may make the process of surgery easier. Chemotherapy can prolong life by eliminating cancer cells that may have already spread to other parts of the body. For T4 tumors, which have migrated outside the bladder, it can be extremely helpful. Surgery to remove the bladder is postponed when chemotherapy is administered beforehand. If the cancer is reduced by chemotherapy, the wait won’t be an issue, but if it keeps growing while receiving treatment, it may become dangerous. On occasion, the chemotherapy decreases the tumor to the point that radiation therapy or intravesical therapy can be used in place of surgery.
After surgery, some patients receive chemotherapy to eradicate any cancer cells that may have remained but were too small to view. It’s unclear if chemotherapy following a cystectomy prolongs a patient’s life, although it may help them remain cancer-free for longer. After surgery, radiation therapy can be required if cancer is discovered in adjacent lymph nodes. Chemotherapy is another possibility, but only if it wasn’t administered prior to surgery.
Some patients with solitary, tiny tumors (some T3) may benefit from treatment with a combination of chemotherapy and radiation after a second, more thorough transurethral resection (TURBT). Repeating a cystoscopy may be necessary if malignancy is still discovered.
Stage 4
These malignancies have spread to distant lymph nodes (M1a) or other areas of the body (M1b), as well as the pelvic or abdominal wall (T4b). Cancers in stage IV are extremely difficult to fully eradicate. In stage 4 cancers there are 2 factors that are in contention of consideration as they dictate the line of treatment to be used. The two subtypes within this stage include –
If the cancer has not spread to the distant parts of the body (M0) – Since surgical removal of these malignancies is highly unlikely, medication is typically the initial course of treatment. Possible course of treatment options include:
- Chemotherapy followed by immunotherapy which typically makes use of the drug Pembrolizumab.
- A combination of chemotherapy and radiation therapy.
The malignancy is usually reexamined using tests such as cystoscopy, TURBT, and imaging after a few treatment cycles. At this stage, additional treatments could include immunotherapy, chemotherapy, radiation therapy, or, if possible, a cystectomy (removal of the bladder).
If the cancer has spread to the distant parts of the body (M1) – Since surgical removal of these malignancies is highly unlikely, the focus may shift on providing palliative care to boost the quality of life and reduce the cytotoxicity of the different lines of treatment. Low dose chemotherapy and immunotherapy are usually the lines of treatment that are followed during this stage.
Summary
Determining the stage of bladder cancer is significant since it allows oncologists to understand the extent of a patient’s malignancy and then accordingly formulate a treatment plan.
