Bladder Cancer (cont.)

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What is chemotherapy for bladder cancer?

Patients who are diagnosed with metastatic bladder cancer (M stage - M1; cancer which has spread to other parts of the body) are usually treated with chemotherapy. Chemotherapy may also be used in cases of "locally advanced" bladder cancer (T stage - T3 and above and/or N stage - N1 and above) in an attempt to decrease the chances of the cancer coming back after radical cystectomy. This is known as "adjuvant chemotherapy." Another strategy entails administering "neoadjuvant chemotherapy" by giving these medications before radical cystectomy in an attempt to improve the results of surgery and decrease the size of the tumor before the operation.

It has been shown that chemotherapy has the potential to control metastatic bladder cancer and increase the chances of cure when used in a neoadjuvant or adjuvant setting along with surgery. However, chemotherapy has its own set of side effects and may not be tolerated by all individuals.

The time-honored chemotherapy regimen for bladder cancer is called the MVAC. It is a combination of four medications given in cyclical form.

Oncologists currently prescribe MVAC in a "dose dense" fashion. This means the patient takes the drugs more frequently than was previously done in the accepted treatment schedule, as well as taking growth factors to help the blood counts to recover faster from the effects of the chemotherapy drugs.The older schedule for MVAC therapy is no longer recommended according to the National Comprehensive Cancer Network.

Some patients with heart disease may not be in a condition to receive Adriamycin and may receive CMV instead (CMV = MVAC without Adriamycin)

An alternative regimen is a combination of gemcitabine (Gemzar) and cisplatin. This is increasingly being used nowadays since some studies have shown that it is equally effective as the MVAC regime with fewer side effects. However, about 40%-50% of patients have medical issues that preclude the use of this therapy.

Cisplatin, which is the main medication in all these regimens, cannot be given to patients who have an abnormal kidney function. In this case, it may be substituted by carboplatin (Paraplatin), which, however, is not as effective as cisplatin-based chemotherapy. Carboplatin-containing regimens are not recommended in place of those containing cisplastin to render the drug cocktail more effective.

Chemotherapy is an ever-changing method to reduce or eliminate cancer cells; it is best for patients to discuss this therapy with their doctors. Variations in chemotherapy treatments occur among clinicians and one patient’s therapy may be quite different from that of another patient. In addition, newer compounds may be introduced at any time that may be advantageous to use instead of conventional chemotherapy agents. The following is a list of compounds that are used by some clinicians to treat various stages of bladder cancer, usually in combination with other anti-cancer cell compounds:

  • Fluorouracil (5-FU)
  • Gemcitabine
  • Pemetrexed
  • Vinblastine
  • Valrubicin
  • Carboplatin
  • Ifosamide
  • Thioepa
  • Docetaxel

A few cancer treatment centers use, in addition to chemotherapy and endoscopic resection, external radiation beam therapy to treat patients. However, the protocol is considered complex with toxicity and high pretreatment mortality (death) rates mainly due to sepsis from the chemotherapy. External beam radiation therapy is mainly used in other countries; it is infrequently used in the United States.

What is the prognosis for bladder cancer?

The most important factors that impact the prognosis (or the chances of control and cure) of bladder cancer are the stage and grade of the tumor. The lower the stage and grade, the better the outlook. Other factors such as number, size, pattern of recurrence (if any), response to initial treatment like BCG, coexistent carcinoma in situ, and certain genetic mutations also play a role. The table below is based on the National Cancer Institute’s data base:

StageRelative 5-Year Survival Rate
SOURCE: National Cancer Institute's SEER database

For low-risk superficial bladder cancer (Ta, low grade), the chances of recurrence are about 50% in five years after the initial diagnosis. This necessitates regular follow-up, even in these low-risk tumors. However, unlike the more aggressive variants of bladder cancer, the chances of progression (for example, chances of the tumor invading into the deeper layers of the bladder) are minimal. Typically, these tumors, even when they recur, do so in the same stage and grade as the original tumor and do not compromise the life expectancy of the patient.

High-risk superficial tumors are those that are high-grade, T1 tumors and are associated with extensive areas of carcinoma in situ. Multiple tumors, large tumors, and those that recur despite BCG treatment are also at an increased risk for recurrence and progression. These tumors have a recurrence rate in the range of 50%-70% at one and five years, respectively. They are also much likely to invade into the deeper layers. These tumors need to be managed and followed up more aggressively since they have a potential to invade and spread to other parts of the body thereby shortening the life expectancy of the patient.

After radical cystectomy, survival depends mostly on the stage of the disease. The five-year disease specific survival for various stages after a radical cystectomy is as follows:

  • T2, N0: 70%-80%
  • T3, N0: 40%-50%
  • T4, N0: 25%-30%
  • N+ (patients with lymph node involvement): 15%-20%
Medically Reviewed by a Doctor on 1/8/2015

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