Urologic surgeon S. Machele Donat is one of several surgeons expert in nerve-sparing techniques and bladder reconstruction procedures that can help preserve sexual and urinary function.
Treatment for bladder cancer varies greatly depending on the stage of disease at the time of diagnosis. At Memorial Sloan-Kettering, a team of surgeons, medical oncologists, radiation oncologists, radiologists, and pathologists — all of whom specialize in the diagnosis and treatment of bladder and other genitourinary cancers (prostate, testis, kidney, and related organs) — work together to make recommendations about how each patient's bladder cancer should be treated.
Noninvasive Bladder Cancer
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Bladder cancer experts from Memorial Sloan-Kettering describe symptoms, risk factors, and diagnosis of the disease.
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The majority of bladder cancers are transitional cell carcinomas (TCCs) that are noninvasive, or confined to the lining of the bladder. The standard treatment for this cancer is a minimally invasive surgical procedure using an instrument called a cystoscope (a thin, lighted instrument used to look inside the bladder) inserted through the urethra to remove tumors or tissue samples.
Patients at high risk for cancer recurrence may also receive bacillus Calmette-Guérin (BCG) therapy after surgery.(1) This therapy is the standard treatment for superficial bladder cancer. BCG uses inactivated tuberculosis bacteria (which cannot cause tuberculosis) to produce an inflammatory response in the bladder; the inflammation controls tumor growth. The treatment is given once a week for six weeks. Afterward physicians usually examine patients with a cystoscope every few months to ensure that the bladder is healthy and tumor free.
Our researchers are also evaluating new drugs as well as targeted therapies to treat patients with superficial bladder cancer whose tumors are not controlled by BCG therapy.
Invasive Bladder Cancer
Surgical removal of the bladder (called a cystectomy) is the most common treatment for invasive bladder cancer — cancer that has spread into or beyond the muscle layer of the bladder wall. Surgery provides the best chance for a long-term cure in most patients with invasive disease that is confined to the pelvis.
When surgeons remove invasive bladder cancer, they also remove the surrounding lymph nodes to help prevent a cancer recurrence or metastasis to other areas of the body. In women, surgeons may also remove the uterus, fallopian tubes, ovaries, and sometimes part of the vaginal wall and the urethra. In men, it is necessary to remove the prostate gland and sometimes the urethra.
As part of this surgery surgeons create a new way for patients to store and eliminate urine. In the traditional approach — an ileal conduit — surgeons use a segment of the small intestine to create a channel through which urine is drained to the skin and into a collection bag.
Memorial Sloan-Kettering's surgeons use an innovative procedure to create a new bladder. They construct the new bladder — called a neobladder — from a segment of the intestine and connect it to the urethra. Patients with a neobladder can urinate through the urethra in a normal fashion. If the patient's urethra has been removed, surgeons can connect the new bladder to a small opening on the skin of the abdominal wall through which urine is drained. Patients with an internal reservoir that is connected to the skin do not have to wear an external collection bag. The neobladder procedure has greatly enhanced the quality of life for many patients with bladder cancer.
For some men with bladder cancer, nerve-sparing techniques — which enable a patient to maintain potency (the ability to have an erection) — are possible depending on the stage of disease. Our surgeons are able to assess who will be the appropriate candidate to undergo a safe nerve-sparing operation. For women, advanced techniques that spare the vagina may be used among select patients to preserve sexual function.
Neoadjuvant or Adjuvant Therapy
Neoadjuvant or adjuvant therapies are treatments administered before or after primary treatment, respectively, to increase the chance of a cure. These therapies may include chemotherapy, radiation therapy, hormone therapy, or biological therapy.
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Memorial Sloan-Kettering experts describe treatments for different types and stages of bladder cancer.
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To treat bladder cancer, chemotherapy can be administered as a “neoadjuvant” (before surgery) or “adjuvant” (after surgery) therapy. The standard of care for advanced bladder cancer is a combination of chemotherapy drugs, which includes methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC). Many patients with muscle-invasive bladder cancer receive chemotherapy before surgery to help prevent a recurrence of cancer by treating cancer cells that may have spread, or metastasized, to other organs even before surgery. Large clinical studies have shown that giving chemotherapy before surgery improves long-term survival.(2) Conversely, some patients who do not receive chemotherapy before surgery may benefit from receiving it afterward. This depends on the extent of the cancer in the bladder and whether it has spread to the surrounding lymph nodes.
Patients and their physicians can use a clinical tool — called a nomogram — to help decide the best treatment plan following surgery. This prediction tool is designed to assess the five-year risk of recurrence for individual patients, which is a key factor in deciding whether adjuvant treatment (for bladder cancer patients this is typically systemic chemotherapy) is likely to be beneficial.(3)
Bladder Preservation
Although many patients with invasive bladder cancer have surgery to remove their bladders, some patients may be eligible for treatment that preserves the bladder and its function. This treatment approach combines radiation therapy and chemotherapy — a combination that heightens the cancer cells' sensitivity to radiation and increases the chance that it will kill the bladder cancer cells.
For this treatment, surgeons first remove the tumor with a cystoscope. Patients then receive a course of radiation therapy to the pelvic lymph nodes and bladder over seven or eight weeks combined with radiosensitizing chemotherapy. During the last several weeks of radiation therapy, patients receive high-precision targeted treatments directed only to the cancerous region within the bladder.
Patients are examined midway through treatment and after it is completed to ensure that the tumor has been eradicated. If the tumors are not eradicated or if they recur, patients may require surgery. Patients who undergo bladder preservation therapy require close, long-term surveillance of the bladder to identify and treat recurrences as early as possible.
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Radiation oncologist Josh Yamada talks about a technique called IGRT that delivers high doses of radiation precisely along the contours of a tumor.
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Our physicians are working to develop new techniques to further improve the targeting accuracy of radiation therapy and to minimize its side effects. Our radiation oncologists use intensity-modulated radiation therapy (IMRT), which allows more precise treatment planning and the ability to deliver higher radiation doses with greater safety. With IMRT, radiation therapists can shape pencil-thin radiation beams of varying intensity to conform to specific tumor shapes and sizes, reducing the dosage of radiation to healthy tissues and possibly the side effects of treatment. In addition, an enhanced form of radiation therapy known as image-guided radiotherapy (IGRT) is used to treat bladder cancer. By incorporating real-time image guidance within IMRT, radiation oncologists can make adjustments in the radiation beam so that radiation is delivered with even more precision.
New approaches in radiation therapy are also under investigation at Memorial Sloan-Kettering. One technique — adapted from standard techniques used in prostate cancer radiotherapy — places “markers” next to cancerous areas in the bladder, which are visible with imaging. These markers help track changes in the bladder's position in the body and allow for corresponding adjustments to be made during treatment, which can lessen the damage to healthy tissue.
Metastatic Bladder Cancer
Metastatic bladder cancer is cancer that has metastasized, or spread, to other organs such as the lungs, liver, or bones. This type of cancer is most commonly treated with chemotherapy designed to shrink the tumors.
At Memorial Sloan-Kettering, first-line treatment for metastatic bladder cancer includes both standard chemotherapeutic regimens as well as novel drug regimens that are available to patients enrolled in clinical trials. These trials aim to improve the effectiveness of standard therapy and include drugs that directly attack the tumor cells as well as drugs that attack cancer cells indirectly by reducing the blood vessels that support their growth, also called angiogenesis. Other new chemotherapy regimens have been developed for use in older patients so that they experience fewer side effects.
Sometimes, if a patient's tumor shrinks following chemotherapy, physicians may consider surgically removing the primary tumor and the surrounding lymph nodes. Our results with this procedure are showing promise for increasing long-term survival.
- H. W. Herr, D. M. Schwalb, Z. F. Zhang, P. C. Sogani, W. R. Fair, W. F. Whitmore Jr, and H. F. Oettgen, Intravesical bacillus Calmette-Guérin therapy prevents tumor progression and death from superficial bladder cancer: ten-year follow-up of a prospective randomized trial, Journal of Clinical Oncology 13(6), 1995: 1404-8.
- Advanced Bladder Cancer Meta-Analysis Collaboration, Neoadjuvant chemotherapy in invasive bladder cancer: a systematic review and meta-analysis, Lancet 361(9373), 2003: 1927-34.
- International Bladder Cancer Nomogram Consortium, B. H. Bochner, M. W. Kattan, and K. C. Vora, Postoperative nomogram predicting risk of recurrence after radical cystectomy for bladder cancer, Journal of Clinical Oncology 24(24), 2006: 3967-72.
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