Chemotherapy Treatment for Bladder Cancer
Chemotherapy is the use of drugs that kill tumor cells and ultimately cancer is treated. A protocol of specific cycles or regimens is followed. After each period of treatment; a small rest period is given to the patient for the body to recover. For the treatment of Bladder Cancer; chemotherapy administration may happen in the following ways:
- Intravesical chemotherapy
This type of chemotherapy is used for bladder cancer that is only in the lining of the bladder. The chemotherapy drug is inserted directly into the bladder.
- Systemic chemotherapy
The chemotherapy drug is administered in the form of a pill or injected into the vein (IV) or muscle (IM). Once administered; the drug enters the bloodstream and is course throughout the body. It is an effective method as the drug can access cancer cells anywhere in the body. There are two modes of administration:
a. Neoadjuvant therapy: During this therapy; surgery is done to shrink the size of the tumor so that it is removed easily from the body. Moreover; it helps lower the chances of cancer relapse.
b. Adjuvant therapy:: It sometimes follows surgery and sometimes radiation therapy. The ultimate goal is to kill any cancer that might have been left during the treatment inside the body. Just like Neoadjuvant therapy it also lowers the chance of cancer recurrence.
Systemic chemotherapy is the primary treatment for metastatic bladder cancers and helps radiation work better.
Chemotherapy drugs in the treatment of bladder cancer
Chemotherapy can be done solely or in combination with other treatments depending on the general health of the patient. Chemotherapy in combination with radiation includes drugs such as:
● Cisplatin plus fluorouracil (5-FU)
● Mitomycin with 5-FU
Common combinations of chemotherapy without radiation include:
● Gemcitabine and cisplatin
● Dose-dense methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (DDMVAC)
● Cisplatin, methotrexate, and vinblastine (CMV)
● Gemcitabine and paclitaxel
Radiation Therapy Treatment For Bladder Cancer
In Radiation therapy; the growth and rapid division of cancer cells is prevented by using high-energy rays. During this local treatment; waves are delivered within the radiation field either externally or internally. There is direct delivery of external editions to cancer from a machine outside the body. Internal radiation involves the implantation of a small amount of radioactive material in or near cancer.
A planning process and simulation before treatment of bladder cancer with radiotherapy helps make careful measurements to find exact angles for administration and the right dosage. Imaging tests like CT or MRI scans can also be included.
During simulation, a simulator machine whose dimensions and movements closely match that of an actual linear accelerator is used on the patients by radiation oncologists and technologists to treat the tumor by projecting an image of it
The simulator room is darkened while the treatment is being set. Temporary marks are made on the patient’s skin with the help of markers. The radiation oncologist along with one or more radiation technologists and often a dosimetrist performs calculations necessary in the treatment planning. It lasts anywhere from 15 minutes to an hour or more, depending on the complexity of the plan.
Another therapy used in the treatment of Bladder Cancer is Palliative therapy that helps reduce the symptoms of cancer and improves the quality of life. It helps shrink cancer lumps and relieve cancer symptoms.
Administration of radiation therapy for bladder cancer is done through linear accelerators that produce high-energy external radiation beams such that it penetrates the tissues and deliver the radiation dose into deeper areas. These machines and other techniques significantly reduce side effects. Moreover, they also help improve the ability to deliver a curative radiation dose to cancer-containing areas and minimize the radiation dose to normal tissue.
The radiation treatment is done in a room separate from the simulation room. The treatment field contains a linear accelerator that focuses on the patient's table. The treatment starts only when the field and calculations are accurate.
Usually, doctors prescribe radiation therapy in combination with chemotherapy for the treatment of patients with stage II-III cancer or recurrent cancer. However, radical cystectomy is the primary step for the treatment of stages II bladder cancer and treatment of stage III bladder cancer.
Other Treatment Options for Bladder Cancer
Biological therapy or Immunotherapy
Low-grade and early-stage cancers are treated by Oncologists with the help of biological therapy or immunotherapy. During this therapy; the immune system is induced to fight the cancer cells and kill them. The most common form is Bacillus Calmette-Guerin therapy (BCG) which causes tuberculosis (TB). During BCG therapy, a catheter helps kill the bacterium by insertion into the bladder.
What is intravesical BCG?
The immune system cells are activated by the BCG Bacteria that can fight any bladder cancer cells that are present. Moreover, it can be inserted into the bladder as a liquid (intravesical BCG). This treatment is done once a week for 6 weeks. It often begins shortly carrying out a TUR(or transurethral resection) which is a surgical procedure for the diagnosis of bladder cancer and removal of tumor lumps from the bladder.
Another option for immunotherapy is interferons. IFNs are a group of signaling proteins that fight infection. A virus-infected cell releases interferons that cause surrounding cells to improve their antiviral defenses. Furthermore, synthetic versions of interferons sometimes in combination with BCG help fight bladder cancer.
Possible side effects of immunotherapy
Common side effects of these drugs include:
● Nausea and vomiting
● Loss of appetite
● Urinary tract infections (UTIs)
● Rash and skin allergies
These drugs work by taking the brakes off the body’s immune system. Hence the immune system can sometimes attack other parts of the body. This causes life-threatening problems in the lungs, intestines, liver, hormone-making glands, or other organs.
Doctors advise patients to report any new side effects right away. However, oncologists stop treatment and administer high doses of steroids; if serious side effects occur, to suppress your immune system.
Bladder Cancer Surgery
Another important treatment modality for most bladder cancers is surgery. The type of surgery depends on the extent of bladder cancer or the stage of cancer, and other factors like the age of the patient, preference, and long-term side-effects that surgery can cause.
Transurethral resection of bladder tumor (TURBT)
Transurethral resection of bladder tumor (TURBT) or transurethral resection (TUR) is another method to detect bladder cancer as well as a common treatment for early-stage non-muscle invasive bladder cancers. The process also provides information on whether cancer has metastasized into the muscle layer of the bladder wall.
During this process; a tube is inserted through the patient’s urethra so there is cutting open the abdomen by administering general anesthesia by drugs or by local anesthesia where the lower portion of the body goes numb. A thin, rigid cystoscope is inserted into the patient’s bladder that helps access tumor cells. It has a wire loop at one end that is used to remove any abnormal tissues or tumors. The tissue is then sent to the lab for testing through biopsy
After removal of the tumor, fulguration ensures that no tumor cells remain inside the body. This method involves high-laser treatment to remove any remaining cells through the resectoscope.
Oncologists advise a cystectomy when bladder cancer is invasive. In many cases; chemotherapy is done before cystectomy.
Partial cystectomy is performed when the cancer is still small but is invasive. During this; cancer is removed via surgery along with part of the bladder wall. The bladder wall is then stitched up. After that; there is a removal of nearby lymph nodes for testing of cancer metastasis. The advantage of this method is that bladder conservation is possible and there is no requirement for reconstructive surgery.
The disadvantage is that the bladder may be incapable of functioning at normalcy or that cancer may relapse.
A radical cystectomy is the first option when the cancer is not large or is prevalent in a greater part of the bladder. It involves the removal of the entire bladder and nearby lymph nodes. In men; prostate and seminal vesicles are removed while in women the ovaries, fallopian tubes, the uterus, cervix, and a small part of the vagina are removed.
In a laparoscopic, or ‘keyhole’ surgery, smaller incisions are made by the surgeon using special long, thin instruments, one of which has a tiny video camera on one end to see inside the patient’s body. The instrument is either held directly by the surgeon or the surgeon may sit at a control panel in the operating room and use robotic arms to do the surgery which is known as a robotic cystectomy. This type of surgery is less painful and quicker recovery because of the smaller cuts. Research is still in process for improvisations and to make it more efficient.
Reconstructive surgery after radical cystectomy
If surgeons suggest removal of the bladder, an alternative is made to store urine which is voided intermittently. The following are a few options:
1. Incontinent diversion
A short piece of the intestine is removed and cut and then connected to the ureters that carry urine out of the kidneys. The urine flows directly from the kidneys through the ureters into the ileal conduit that connects the skin on the front of the abdomen by an opening called a stoma
A small bag is stuck to the skin of the patient’s belly around the stoma to collect the urine. Urine slowly drains out non-stop in a urine bag that and should be emptied whenever it is full. This procedure is known as an incontinent diversion because the patient cannot control the flow of urine out of the body.
2. Continent diversion
In this a pouch is made from a piece of intestine is attached to the ureters. One end of the pouch is connected to an opening or the stoma in the skin on the front of the belly. A one-way valve at the opening is created by the surgery that allows the storage of urine in the pouch. By inserting a catheter into the stoma through the valve; the patient then empties it several times a day. This method is preferable because of the absence of the urine bag.
This method routes the urine back into the urethra by creating a new bladder or a neobladder from a piece of intestine. The ureters are sewn to the neobladder that allows patients to urinate normally on a schedule. Over time, incontinence may persist at night; but most patients regain the ability to urinate normally during the day.