Bladder Cancer (cont.)
Kevin C. Zorn, MD, FRCSC, FACS
Gagan Gautam, MD, MCh
Charles Patrick Davis, MD, PhD
Charles Patrick Davis, MD, PhD
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
In this Article
What is the treatment of superficial bladder cancer?
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Superficial bladder cancer is a cancer which has not invaded the muscle wall of the bladder and is confined to the inner lining of the bladder. The T stage is Ta, T1, or Tis (also known as carcinoma in situ or "CIS"). After the initial TURBT or biopsy in case of CIS, the subsequent treatment in these cases may involve observation with regular follow-up with cystoscopy examinations of the bladder, instillation of medications in the bladder, or in certain cases, surgical removal of the bladder (radical cystectomy).
Small low-grade, superficial bladder cancers may not require aggressive management after the initial TURBT and may be simply followed up by doing repeated cystoscopy examinations at regular intervals (usually every three months for the initial two years and then at increasing intervals). Recurrent tumors may be surgically removed or fulgurated (burnt out) with special instruments passed through the cystoscope. It is very important to note that 30% to 40% of these tumors tend to recur and these recurrences may not be associated with any symptoms. Hence, it is imperative to stick to a regular follow-up protocol to ensure that the disease does not go out of control. It has also been shown that a single dose of a chemotherapy medication (for example, mitomycin C [Mutamycin]) put inside the bladder immediately after a TURBT can decrease the chances of recurrence within the first two years after surgery.
High-grade, larger, multiple, or recurrent superficial bladder cancers may require additional treatment after the initial TURBT. One of the most effective and widely used medications is called the Bacille Calmette Guerin, commonly referred to as BCG. It is a modified form of a bacterium that causes tuberculosis in cattle (Mycobacterium bovis). It is instilled into the bladder in the form of a solution using a catheter placed in the urinary passage. It acts by stimulating the immune system of the body to act against the cancerous bladder cells and prevent their growth and development. It has been shown to decrease the chances of recurrence of bladder cancer as well as its invasion into the muscle layer of the bladder. However, it is only partially effective in achieving these objectives and its use does not obviate the need for a regular follow-up. It is usually administered in six initial doses at weekly intervals followed by a "maintenance" schedule which is usually recommended for at least once per year but may be needed for as long as three years.
Patients, who do not respond to BCG treatment, recur in spite of treatment or those who have medical issues which preclude the use of BCG, may require other forms of treatment. These include bladder instillation of immunotherapy agents such as Interferon or chemotherapy medicines like valrubicin (Valstar), mitomycin C, epirubicin (Ellence), or doxorubicin (Adriamycin). In general, these medications are not as effective as BCG and help only a small minority of patients who have not responded to BCG.
In patients who have an aggressive form of high-grade superficial bladder cancer and those who have not responded or recurred in spite of treatments mentioned above, a more aggressive form of treatment may be warranted. This is usually in the form of a major surgical procedure called radical cystectomy. It entails removal of the bladder and the prostate and diverting the urinary stream using parts of the intestine. This surgery will be described in the subsequent section on treatment of invasive bladder cancer.
Reviewed by Charles Patrick Davis, MD, PhD on 11/26/2013
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