Treatment of Recurrent Bladder Cancer

Treatment for recurrent bladder cancer (bladder cancer that has come back after successful treatment) depends on what type of treatment you received before, where the cancer came back, and other factors.

If you had a superficial cancer that has returned to the bladder and has not spread to other parts of the body, you will probably receive the type of treatment, including transurethral resection (TUR), usually given for Stage 0, Stage I, or Stage II bladder cancer.

• Transurethral resection (TUR), also known as transurethral resection of the bladder tumor (TURBT) - The urologist places a rigid cystoscope (thin lighted tube) called a resectoscope into the bladder through the urethra while you are under regional or general anesthetic. The resectoscope lets the urologist see into the bladder and remove the tumor using a wire loop at the end of the resectoscope. The surgeon can also burn the tumor off using a laser or high-energy electricity (fulguration).

If your tumor continues to come back to the bladder or if your tumor has become invasive or aggressive, you will eventually need a cystectomy.

• Cystectomy - Cystectomy is used to remove the diseased area by cutting through the bladder wall. Cystectomy can be partial or radical:
  
  
  • Partial or segmental cystectomy - The surgeon removes only the cancer and part of the bladder. This surgery is sometimes used for low-grade tumors that have invaded the wall of the bladder but are only found in one area of the bladder. Because only a part of the bladder is removed, patients can urinate normally after recovering from this surgery.
  • Radical cystectomy - The surgeon removes the bladder and tissue around the bladder as well as any lymph nodes (small, bean-shaped collections of immune system cells that help fight infections) and nearby organs that contain cancer. For men, the prostate may also be taken out. For women, the surgeon might also remove the uterus (womb), ovaries, and a small portion of the vagina and fallopian tubes (which connect the ovaries and uterus).
    

If you have radical cystectomy, you will require urinary diversion.

• Urinary diversion - Urinary diversion allows your body to store and remove urine without a bladder. Your surgeon may use a piece of your small intestine to create a new tube through which urine can pass. The surgeon attaches one end of the tube to the ureters and the other end to a new opening, called a stoma, in the wall of the abdomen. You then use a catheter (a thin, flexible tube) to drain the urine. The operation to create the stoma is called a urostomy or ostomy.
  

  In another type of reconstructive surgery, the doctor uses 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 a stoma. If the surgeon is able to connect the pouch to the urethra and create a “neobladder” (new bladder), you will be able to urinate normally.  

If your tumor has come back to other parts of the body, beyond the bladder, you might be treated with chemotherapy.

• Systemic (whole-body) chemotherapy - Anticancer drugs are injected into a vein or given by mouth. These medicines travel through the bloodstream to all parts of the body. Unlike intravesical or local chemotherapy, systemic chemotherapy can attack cancer cells that have already spread beyond the bladder to lymph nodes (small, bean-shaped collections of immune system cells that help fight infections) and other organs. These drugs kill cancer cells but can also damage some normal cells. This damage to normal cells can cause side effects.

The drugs used most often for systemic chemotherapy for Stage IV bladder cancer are:

• Adriamycin^® (doxorubicin) - Doxorubicin hydrochloride belongs to the group of chemotherapy drugs known as anthracycline antibiotics. It stops the growth of cancer cells, causing them to die. This drug is given by a shot in a vein over about 15 minutes. The dose and how often you get the medicine depend on your size, your blood counts, how well your liver works, and the type of cancer you have.
• Cytoxan^® or Neosar^® (cyclophosphamide) - Cyclophosphamide belongs to a group of chemotherapy drugs known as alkylating agents. It stops the growth of cancer cells, causing them to die. This drug can be given by mouth as a pill or liquid, or by a shot into a vein. The dose depends upon your size and your type of cancer.
• Gemzar^® (gemcitabine) - Gemcitabine belongs to a group of chemotherapy drugs known as antimetabolites. It prevents cells from making DNA and RNA, which stops the growth of cancer cells and causes the cells to die. Gemcitabine is given by an injection into a vein over 30 minutes. It is usually given once a week for 3 weeks, followed by a week off. The dose depends on your size, your blood counts, and type of cancer you have.
• Platinol^® (cisplatin) - Cisplatin is a platinum compound chemotherapy drug that acts like an alkylating agent. It stops the growth of cancer cells, causing them to die. Cisplatin is given by an injection into the vein over at least 1 hour. Your dose depends upon the type of cancer you have, your size, and how well your kidneys work.
• Rheumatrex^® or Trexall™ (methotrexate) - Methotrexate belongs to a group of chemotherapy drugs known as antimetabolites. It prevents cells from making DNA and RNA, which stops the growth of cancer cells. Methotrexate is given as a pill by mouth, an injection into a vein for up to 20 minutes, or an injection into a muscle. The dose depends on your size, the type of cancer you have, and how well your kidneys work.
• Taxol^® or Onxol^® (paclitaxel) - Paclitaxel belongs to the group of chemotherapy drugs known as taxanes. It is also called a mitotic inhibitor because it affects the cell during mitosis (cell division). It stops cell division, resulting in cell death. Paclitaxel is given by an injection into a vein, usually over a 3-hour period, every 3 weeks. Sometimes, smaller doses are given once a week over shorter periods. The dose depends on your weight, how well your liver works, the side effects you experience, and how often the medicine is given.
• Velban^® (vinblastine) - Vinblastine belongs to the group of chemotherapy drugs known as plant (vinca) alkaloids. It stops cell division, resulting in cell death. Vinblastine is given by an injection into a vein over 5 to 10 minutes. The dose and how often you get the medicine depends on your weight, your blood counts, how well your liver works, and the type of cancer you have.
  

Combinations of chemotherapy drugs are often more effective than individual drugs in treating bladder cancer. The combinations used most often for recurrent bladder cancer are:

• M-VAC (methotrexate, vinblastine, doxorubicin [Adriamycin], and cisplatin)
• GemCIS (gemcitabine and cisplatin)
• MCV (methotrexate, cisplatin, and vinblastine)
• DI-MVAC + G-CSF (a high dose of [dose-intense] M-VAC given with granulocyte colony-stimulating factor, also known as filgrastim, a growth factor that stimulates the bone marrow to make white blood cells)

If your cancer spread and causes symptoms such as pain, you might also be treated with external beam radiation therapy.

• External beam radiation therapy (EBRT) - EBRT focuses radiation from outside the body on the cancer. Most people are treated with EBRT 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. 

This content has been reviewed and approved by Myo Thant, MD.