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• Types of Cancer
• Bladder Cancer
• Am I at risk?
• Can I get screened?
• How do you diagnose it?
• What are the Symptoms of Bladder Cancer?
• What are the treatment options?
• What is Bladder Cancer?

Treatments for bladder cancer are based on the stage of the cancer at time of diagnosis, as well as the particular cell type. At John Muir Health, bladder preservation is always a treatment goal, wherever possible. Your physician will recommend an individualized treatment plan that may include surgery, biologic therapy, radiation therapy, chemotherapy, or several of these options used in tandem. The use of multiple treatments is known as combined modality therapy.

Surgical Procedures

John Muir Health offers the full range of advanced surgical options for the treatment of bladder cancer, including minimally invasive cystoscopic procedures, radical cystectomy, the latest nerve-sparing techniques, and the newest options for urinary diversion. Our exceptional surgical teams on both campuses include board-certified urologists and highly-trained surgical nurses and technicians.

Depending on the stage and the aggressiveness of the cancer, patients may undergo chemotherapy and/or radiation therapy, either before or after surgery. Patients with superficial or early-stage cancer may undergo one or regimens of intravesical biologic therapy or chemotherapy after minimally invasive surgery.

The major surgical procedures for bladder cancer are:

Cystoscopy/Transurethral Resection - Cystoscopy is used both in the diagnosis and the treatment of bladder cancer. A slender lighted tube (the cystoscope) with a lens attached is inserted into the bladder via the urethra. Operating surgical instruments through the cystoscope, surgeons can cut away areas of superficial bladder cancer. This is known as transurethral resection (TUR). Another procedure called fulguration is sometimes performed, in which cancer is burned away via an electric probe inserted into the cystoscope. Cancers that have deeply invaded the bladder wall cannot be removed through a cystoscope. Following surgery, some patients may undergo a regimen of biologic therapy (BCG).

Radical Cystectomy - Patients with advanced bladder cancer or aggressive forms of superficial cancer usually undergo radical cystectomy, which consists of removal of the bladder, adjacent lymph nodes, and, when necessary, other structures such as the urethra or lower portions of the ureters. Because of the proximity of the reproductive organs, male patients sometimes require prostate excision; in women, the uterus, fallopian tubes, ovaries, and portions of the vaginal wall may need to be removed. During conventional radical cystectomy, nerves in the pelvic area may be damaged or removed, affecting sexual function and response in both men and women. Using nerve-sparing techniques, the surgeon carefully cuts cancerous tissue away from the nerve bundles associated with sexual function, without damaging them. Nerve-sparing surgery is not always possible. If the cancer is too extensive or not ideally situated, the nerves may need to be sacrificed to ensure that all cancerous tissue has been removed.

Urinary Diversion Options

Since patients who undergo radical cystectomy no longer have a bladder, an alternative means for the body to store and eliminate urine must be created. This process is known as urinary diversion surgery.

Several different urinary diversion options are now available. The traditional ileal conduit approach - which is still the best option for certain patients - entails the creation of a conduit for urine using a portion of the small intestine. The conduit transports urine directly from the kidneys to an opening (a stoma) made in the patient's abdominal wall. The urine is then collected in an external bag, which must be periodically emptied by the patient.

Alternative methods of urinary diversion now available for appropriate patients eliminate the need for an external collection bag, an important patient benefit. These methods involve the construction of an internal continent reservoir (or storage pouch) for urine, using portions of the intestine. There are two main categories of continent reservoir- approaches: orthotopic neobladder and continent cutaneous diversion.

The orthotopic neobladder is an exciting new option at John Muir Health for appropriate patients who still have their urethras. The artificial reservoir is connected directly to the urethra, enabling the patient to urinate naturally. No collection bags or catheters are needed.

In continent cutaneous diversion - an approach used in patients who no longer have a urethra - the reservoir is connected to a stoma in the abdominal wall. Urine is stored in the reservoir until the patient empties it by inserting a catheter through the stoma into the reservoir. There is no need for an external bag, because urine remains in the reservoir.

The type of urinary diversion method that is best for your particular situation depends on many different factors, including the stage and location of your cancer, your age and general health, and your attitude toward the available options. Your physician will help you to evaluate the advantages and disadvantages of each option to determine the best approach.

Chemotherapy

Chemotherapy - or the use of cancer-killing drugs - is sometimes used alone or in combination with radiation therapy following surgical removal of the bladder to help prevent cancer recurrence. In certain instances, chemotherapy may be administered before surgery as well. (Patients with superficial bladder cancer may undergo intravesical chemotherapy, which is discussed separately.) Chemotherapy and/or radiation therapy administered after surgery is known as adjuvant therapy. When given before surgery, it is called neoadjuvant therapy.

Patients with metastatic bladder cancer not conducive to surgical removal may undergo systemic chemotherapy, using a combination of anticancer drugs. Several new drugs for metastatic disease - including gemcitabine and taxol - are now being used at John Muir Health.

Through its active research program, with regional and national affiliations, John Muir Health can provide patients with access to investigational chemotherapy drugs as well.

Biologic Therapy

Many patients with superficial bladder cancer are candidates for a highly effective, minimally invasive treatment known as "biologic" therapy, which fights bladder cancer by stimulating the patient's own immune system. A solution containing a substance known as bacillus Calmette-Guerin (BCG) - an inactivated tuberculosis bacterium incapable of causing disease - is instilled via the urethra directly into the bladder (intravesical therapy). BCG produces an inflammatory response within the bladder that may control tumor growth. Most patients respond well to BCG, and the side effects are very tolerable for most.

Generally, patients will undergo weekly instillations of BCG over a period of six weeks. Some patients will need to undergo more than one six-week BCG regimen. After treatment, many patients will be placed on a "maintenance" regimen, where they undergo periodic, short-term regimens of BCG to help prevent cancer recurrence.

For patients with superficial bladder cancer who do not respond to BCG therapy, there are several different intravesical chemotherapy treatments that may be tried, including such drugs as thiotepa or mitomycin. (Intravesical chemotherapy differs from systemic chemotherapy, which is discussed separately.) If patients are not responsive to intravesical therapy, or if there is a cancer recurrence, surgical removal of the bladder is usually necessary.

Radiation Therapy

For patients with advanced bladder cancer, radiation therapy is sometimes used after surgical removal of the bladder - either alone or in combination with chemotherapy - to eradicate any remaining cancer cells and to help prevent cancer recurrence. Postoperative radiation therapy is known as adjuvant therapy.

In some advanced cancers that are not conducive to surgical removal, radiation therapy may be used alone to help alleviate painful symptoms.

The type of radiation therapy used in bladder cancer is external beam radiation, in which the affected area is radiated from outside the body via a precisely targeted beam of radiation from special equipment called a linear accelerator. Before radiation therapy, patients may be given radiosensitizing chemotherapy drugs, which help to enhance the cancer-killing efficiency of radiation.

John Muir Health is one of northern California's premier centers for radiation therapy, with a reputation for clinical excellence and cutting-edge technology. Our state-of-the-art equipment includes five linear accelerators and two dedicated CT scanners to ensure the most precise and effective radiation therapy available. The advanced radiation therapy capabilities at John Muir Health include:

• Three-Dimensional Conformal Treatment - This sophisticated form of external beam therapy uses a computerized treatment planning system that optimizes radiation therapy by pinpointing the location of the tumor with the highest level of precision possible. This capability is very important in planning the most effective therapies for bladder cancer. Special features on the linear accelerator called multi-leaf collimators enable the radiation beam to be "shaped" to closely conform to the contours of the tumor. This permits a higher dose of radiation to be administered directly to the bladder, while diminishing the radiation dose to surrounding tissue, thereby increasing cancer-killing effectiveness while minimizing toxicity.
• Intensity-Modulated Radiation Therapy (IMRT) is a newly introduced enhancement of the technology used in three-dimensional conformal therapy. Specialized treatment planning software is used to development a precise plan that "modulates" or varies the radiation used in each treatment session. The highest possible doses of radiation can be applied directly to the bladder, while lower doses are applied to areas adjacent to organs and critical structures that need to be protected.

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