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bladder cancer treatment





Contents
  • Preparing for treatment
  • Methods of treating bladder cancer
  • Side effects
  • Surgery
  • Radiation therapy
  • Chemotherapy
  • Biological therapy
  • Nutrition
  • Rehabilitation
  • Follow-up care
  • Support
  • The promise of research
  • Many people with bladder cancer want to take an active part in decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, the shock and stress that people often feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some patients also want to have a family member or friend with them when they talk to the doctor – to take part in the discussion, to take notes, or just to listen.

    The doctor may refer patients to doctors who specialize in treating cancer, or patients may ask for a referral. Treatment generally begins within a few weeks after the diagnosis. There will be time for patients to talk with the doctor about treatment choices, get a second opinion, and learn more about bladder cancer.


    Getting a second opinion

    Before starting treatment, a patient may want to get a second opinion about the diagnosis, the stage of cancer, and the treatment plan. Some insurance companies require a second opinion; others may cover a second opinion if the patient requests it. Gathering medical records and arranging to see another doctor may take a little time. In most cases, a brief delay does not make treatment less effective.

    There are a number of ways to find a doctor for a second opinion:
    • The doctor may refer patients to one or more specialists. Specialists who treat bladder cancer include surgeons, urologists, medical oncologists, radiation oncologists, and urologic oncologists. At cancer centers, these doctors often work together as a team.


    • The Cancer Information Service (in the U.S.), at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute.


    • People can get the names of specialists from their local medical society, a nearby hospital, or a medical school.


    • The American Board of Medical Specialties (ABMS) has a list of doctors who have met certain education and training requirements and have passed specialty examinations. The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. The directory is available in most public libraries.

    Preparing for treatment

    The doctor develops a treatment plan to fit each patient's needs. Treatment depends on the type of bladder cancer, the stage of the disease, and the grade of the tumor. (The grade tells how closely the cancer cells resemble normal cells. It suggests how fast the cancer is likely to grow. Low-grade cancers usually grow and spread more slowly than high-grade cancers.) The doctor also considers other factors, including the patient's age and general health.

    These are some questions a patient may want to ask the doctor before treatment begins:
    • What kind of bladder cancer do I have?
    • What is the stage of the disease? Has the cancer spread?
    • What is the grade of the tumor?
    • What are my treatment choices? Which do you recommend for me? Why?
    • What are the expected benefits of each kind of treatment?
    • What are the risks and possible side effects of each treatment?
    • What is the treatment likely to cost? Is this treatment covered by my insurance plan?
    • How will treatment affect my normal activities?
    People do not need to ask all of their questions or understand all of the answers at once. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.





    Methods of treating bladder cancer

    People with bladder cancer have many treatment options. They may have surgery, radiation therapy, chemotherapy, or biological therapy. Some patients get a combination of therapies.

    The doctor is the best person to describe treatment choices and discuss the expected results of treatment.

    A patient may want to talk to the doctor about taking part in a clinical trial, a research study of new treatment methods. Clinical trials are an important option for people with all stages of bladder cancer. The section on "The promise of cancer research" has more information about clinical trials.


    Surgery

    Surgery is a common treatment for bladder cancer. The type of surgery depends largely on the stage and grade of the tumor. The doctor can explain each type of surgery and discuss which is most suitable for the patient:
    • Transurethral resection. The doctor may treat early (superficial) bladder cancer with transurethral resection (TUR). During TUR, the doctor inserts a cystoscope into the bladder through the urethra. The doctor then uses a tool with a small wire loop on the end to remove the cancer and to burn away any remaining cancer cells with an electric current. (This is called fulguration.) The patient may need to be in the hospital and may need anesthesia. After TUR, patients may also have chemotherapy or biological therapy.


    • Radical cystectomy. For invasive bladder cancer, the most common type of surgery is radical cystectomy. The doctor also chooses this type of surgery when superficial cancer involves a large part of the bladder. Radical cystectomy is the removal of the entire bladder, the nearby lymph nodes, part of the urethra, and the nearby organs that may contain cancer cells. In men, the nearby organs that are removed are the prostate, seminal vesicles, and part of the vas deferens. In women, the uterus, ovaries, fallopian tubes, and part of the vagina are removed.


    • Segmental cystectomy. In some cases, the doctor may remove only part of the bladder in a procedure called segmental cystectomy. The doctor chooses this type of surgery when a patient has a low-grade cancer that has invaded the bladder wall in just one area.

    Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, the surgeon removes the bladder but does not try to get rid of all the cancer. Or, the surgeon does not remove the bladder but makes another way for urine to leave the body. The goal of the surgery may be to relieve urinary blockage or other symptoms caused by the cancer.

    When the entire bladder is removed, the surgeon makes another way to collect urine. The patient may wear a bag outside the body, or the surgeon may create a pouch inside the body with part of the intestine. The sections on "Side Effects of Treatment" and "Rehabilitation" have more information about these procedures.

    These are some questions a patient may want to ask the doctor about surgery:
    • What kind of operation will it be?
    • How will I feel afterward?
    • What will you do for me if I have pain?
    • How long will I have to stay in the hospital?
    • Will I have any long-term effects?
    • When can I get back to my normal activities?
    • Will I urinate in a normal way?
    • Will the surgery affect my sex life?
    • How often will I need checkups?

    Radiation therapy

    Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. Like surgery, radiation therapy is local therapy. It affects cancer cells only in the treated area.

    A small number of patients may have radiation therapy before surgery to shrink the tumor. Others may have it after surgery to kill cancer cells that may remain in the area. Sometimes, patients who cannot have surgery have radiation therapy instead.

    Doctors use two types of radiation therapy to treat bladder cancer:
    • External radiation. A large machine outside the body aims radiation at the tumor area. Most people receiving external radiation are treated 5 days a week for 5 to 7 weeks as an outpatient. This schedule helps protect healthy cells and tissues by spreading out the total dose of radiation. Treatment may be shorter when external radiation is given along with radiation implants.


    • Internal radiation. The doctor places a small container of a radioactive substance into the bladder through the urethra or through an incision in the abdomen. The patient stays in the hospital for several days during this treatment. To protect others from radiation exposure, patients may not be able to have visitors or may have visitors for only a short period of time while the implant is in place. Once the implant is removed, no radioactivity is left in the body.

    Some patients with bladder cancer receive both kinds of radiation therapy.

    These are some questions a patient may want to ask the doctor about radiation therapy:
    • Why do I need this therapy?
    • How will the radiation be given?
    • Will I need to stay in the hospital? For how long?
    • When will the treatments begin? When will they end?
    • How will I feel during therapy? Are there side effects?
    • What can I do to take care of myself during treatment?
    • How will we know if the radiation is working?
    • Will I be able to continue my normal activities during treatment?
    • How often will I need checkups?

    Chemotherapy

    Chemotherapy uses drugs to kill cancer cells. The doctor may use one drug or a combination of drugs.

    For patients with superficial bladder cancer, the doctor may use intravesical chemotherapy after removing the cancer with TUR. This is local therapy. The doctor inserts a tube (catheter) through the urethra and puts liquid drugs in the bladder through the catheter. The drugs remain in the bladder for several hours. They mainly affect the cells in the bladder. Usually, the patient has this treatment once a week for several weeks. Sometimes, the treatments continue once or several times a month for up to a year.

    If the cancer has deeply invaded the bladder or spread to lymph nodes or other organs, the doctor may give drugs through a vein. This treatment is called intravenous chemotherapy. It is systemic therapy, meaning that the drugs flow through the bloodstream to nearly every part of the body. The drugs are usually given in cycles so that a recovery period follows every treatment period.

    The patient may have chemotherapy alone or combined with surgery, radiation therapy, or both. Usually chemotherapy is an outpatient treatment given at the hospital, clinic, or at the doctor's office. However, depending on which drugs are given and the patient's general health, the patient may need a short hospital stay.


    Biological therapy

    Biological therapy (also called immunotherapy) uses the body's natural ability (immune system) to fight cancer. Biological therapy is most often used after TUR for superficial bladder cancer. This helps prevent the cancer from coming back.

    The doctor may use intravesical biological therapy with BCG solution. BCG solution contains live, weakened bacteria. The bacteria stimulate the immune system to kill cancer cells in the bladder. The doctor uses a catheter to put the solution in the bladder. The patient must hold the solution in the bladder for about 2 hours. BCG treatment is usually done once a week for 6 weeks.

    Patients may want to ask these questions about chemotherapy or biological therapy:
    • Why do I need this treatment?
    • What drug will I get? How will it be given? What will it do?
    • Will I have side effects? What can I do about them?
    • How long will I be on this treatment?
    • How often will I need checkups?

    Side effects

    Because cancer treatment may damage healthy cells and tissues, unwanted side effects sometimes occur. These side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Doctors and nurses will explain the possible side effects of treatment and how they will help the patient manage them.


    Surgery

    For a few days after TUR, patients may have some blood in their urine and difficulty or pain when urinating. Otherwise, TUR generally causes few problems.

    After cystectomy, most patients are uncomfortable during the first few days. However, medicine can control the pain. Patients should feel free to discuss pain relief with the doctor or nurse. Also, it is common to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each person.

    After segmental cystectomy, patients may not be able to hold as much urine in their bladder as they used to, and they may need to urinate more often. In most cases, this problem is temporary, but some patients may have long-lasting changes in how much urine they can hold.

    If the surgeon removes the bladder, the patient needs a new way to store and pass urine. In one common method, the surgeon uses a piece of the person's small intestine to form a new tube through which urine can pass. The surgeon attaches one end of the tube to the ureters and connects the other end to a new opening in the wall of the abdomen. This opening is called a stoma. A flat bag fits over the stoma to collect urine, and a special adhesive holds it in place. The operation to create the stoma is called a urostomy or an ostomy. The section called "Rehabilitation after bladder cancer" has more information about how patients learn to care for the stoma.

    For some patients, the doctor is able to use a part of the small intestine to make a storage pouch (called a continent reservoir) inside the body. Urine collects in the pouch instead of going into a bag. The surgeon connects the pouch to the urethra or to a stoma. If the surgeon connects the pouch to a stoma, the patient uses a catheter to drain the urine.

    Bladder cancer surgery may affect a person's sexual function. Because the surgeon removes the uterus and ovaries in a radical cystectomy, women are not able to get pregnant. Also, menopause occurs at once. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause. Many women take hormone replacement therapy (HRT) to relieve these problems. If the surgeon removes part of the vagina during a radical cystectomy, sexual intercourse may be difficult.

    In the past, nearly all men were impotent after radical cystectomy, but improvements in surgery have made it possible for some men to avoid this problem. Men who have had their prostate gland and seminal vesicles removed no longer produce semen, so they have dry orgasms. Men who wish to father children may consider sperm banking before surgery or sperm retrieval later on.

    It is natural for a patient to worry about the effects of bladder cancer surgery on sexuality. Patients may want to talk with the doctor about possible side effects and how long these side effects are likely to last. Whatever the outlook, it may be helpful for patients and their partners to talk about their feelings and help one another find ways to share intimacy during and after treatment.


    Radiation therapy

    The side effects of radiation therapy depend mainly on the treatment dose and the part of the body that is treated. Patients are likely to become very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.

    External radiation may permanently darken or "bronze" the skin in the treated area. Patients commonly lose hair in the treated area and their skin may become red, dry, tender, and itchy. These problems are temporary, and the doctor can suggest ways to relieve them.

    Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. The doctor can suggest medicines to ease these problems.

    Radiation therapy also may cause a decrease in the number of white blood cells, cells that help protect the body against infection. If the blood counts are low, the doctor or nurse may suggest ways to avoid getting an infection. Also, the patient may not get more radiation therapy until blood counts improve. The doctor will check the patient's blood counts regularly and change the treatment schedule if it is necessary.

    For both men and women, radiation treatment for bladder cancer can affect sexuality. Women may experience vaginal dryness, and men may have difficulty with erections.

    Although the side effects of radiation therapy can be distressing, the doctor can usually treat or control them. It also helps to know that, in most cases, side effects are not permanent.


    Chemotherapy

    The side effects of chemotherapy depend mainly on the drugs and the doses the patient receives as well as how the drugs are given. In addition, as with other types of treatment, side effects vary from patient to patient.

    Anticancer drugs that are placed in the bladder cause irritation, with some discomfort or bleeding that lasts for a few days after treatment. Some drugs may cause a rash when they come into contact with the skin or genitals.

    Systemic chemotherapy affects rapidly dividing cells throughout the body, including blood cells. Blood cells fight infection, help the blood to clot, and carry oxygen to all parts of the body. When anticancer drugs damage blood cells, patients are more likely to get infections, may bruise or bleed easily, and may have less energy. Cells in hair roots and cells that line the digestive tract also divide rapidly. As a result, patients may lose their hair and may have other side effects such as poor appetite, nausea and vomiting, or mouth sores. Usually, these side effects go away gradually during the recovery periods between treatments or after treatment is over.

    Certain drugs used in the treatment of bladder cancer also may cause kidney damage. To protect the kidneys, patients need a lot of fluid. The nurse may give the patient fluids by vein before and after treatment. Also, the patient may need to drink a lot of fluids during treatment with these drugs.

    Certain anticancer drugs can also cause tingling in the fingers, ringing in the ears, or hearing loss. These problems may go away after treatment stops.


    Biological therapy

    BCG therapy can irritate the bladder. Patients may feel an urgent need to urinate, and may need to urinate frequently. Patients also may have pain, especially when urinating. They may feel tired. Some patients may have blood in their urine, nausea, a low-grade fever, or chills.


    Nutrition

    Patients need to eat well during cancer therapy. They need enough calories to maintain a good weight and protein to keep up strength. Good nutrition often helps people with cancer feel better and have more energy.

    But eating well can be difficult. Patients may not feel like eating if they are uncomfortable or tired. Also, the side effects of treatment, such as poor appetite, nausea, or vomiting, can be a problem. Foods may taste different.

    The doctor, dietitian, or other health care provider can suggest ways to maintain a healthy diet.


    Rehabilitation

    Rehabilitation is an important part of cancer care. The health care team makes every effort to help the patient return to normal activities as soon as possible.

    Patients who have a stoma need to learn to care for it. Enterostomal therapists or nurses can help. These health care specialists often visit patients before surgery to discuss what to expect. They teach patients how to care for themselves and their stomas after surgery. They talk with patients about lifestyle issues, including emotional, physical, and sexual concerns. Often they can provide information about resources and support groups.


    Follow-up care

    Followup care after treatment for bladder cancer is important. Bladder cancer can return in the bladder or elsewhere in the body. Therefore, people who have had bladder cancer may wish to discuss the chance of recurrence with the doctor.

    If the bladder was not removed, the doctor will perform cystoscopy and remove any new superficial tumors that are found. Patients also may have urine tests to check for signs of cancer. Followup care may also include blood tests, X-rays, or other tests.

    People should not hesitate to discuss followup care with the doctor. Regular followup ensures that the doctor will notice changes so that any problems can be treated as soon as possible. Between checkups, people who have had bladder cancer should report any health problems as soon as they appear.


    Support for people with bladder cancer

    Living with a serious disease such as cancer is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with the disease and the effects of treatment. Patients may want to talk with a member of their health care team about finding a support group.

    People living with cancer may worry about caring for their families, holding on to their jobs, or keeping up with daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team will answer questions about treatment, working, or other activities. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for help with rehabilitation, emotional support, financial aid, transportation, or home care.


    The promise of research

    Doctors all over the country are conducting many types of clinical trials. These are research studies in which people take part voluntarily. Doctors are studying ways to treat bladder cancer and prevent it from coming back. Research already has led to advances in these areas, and researchers continue to search for more effective approaches.

    Patients who join clinical trials have the first chance to benefit from new treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease. Although clinical trials may pose some risks, researchers take many steps to protect their patients.

    Patients who are interested in joining a clinical study should talk with their doctor.

    Doctors are studying surgery, radiation therapy, chemotherapy, biological therapy, and combinations of these types of treatment. Another approach under study is photodynamic therapy, which uses drugs that start to work when exposed to light. After the cancer cells absorb the drug, the doctor shines a special light inside the bladder through a cystoscope. The drug becomes active and kills the cancer cells.

    Doctors also are studying whether large doses of vitamins or certain drugs may prevent bladder cancer from coming back after treatment.


    Related category

       • HEALTH AND DISEASE

    Source: National Cancer Institute