Bladder Cancer Treatment-Part 2
Combination Treatment
Combination radiation and chemotherapy (the bladder-sparing option) is generally reserved for patients who are medically unfit for surgery or who refuse surgery for other reasons. Those who undergo this combination procedure may experience side effects from both the chemotherapy and the radiation.
The usual course of radiation is approximately forty daily treatments delivered over eight weeks. Patients can miss an occasional day, but prolonged interruptions should be avoided because it reduces the effectiveness of the radiation.
A dose of 5,000 units are delivered over a five- to six-week period. The patient is then cystoscoped again by the urologist. If there is a total, or almost total, response, the patient will receive an additional 2,000 units of radiation over a two- to three-week period. A total of 7,000 units of radiation may be delivered to the bladder and surrounding lymph nodes on a daily basis over this period. Treatment is directed through the front, back, and sides of the patient; and the treatment field is shaped to treat the bladder and adjacent lymph nodes while avoiding the bowel as much as possible. The patient receives chemotherapy concurrent with the radiation therapy.
If the patient has a poor response to combination treatment, then the patient is advised to have surgery. If the person is unfit for surgery, the options include radiation or chemotherapy alone, with the objective of temporarily reducing growth rate or controlling bleeding or pain.
If the patient does not respond to the combination or individual therapies, has significant side effects of treatment, and also is not considered a suitable candidate for surgery, then sometimes the best option is to stop all treatment other than supportive care. Because of poor physical condition, some patients may not be able to tolerate surgery or combination chemotherapy and radiation, although they may be candidates for radiation therapy alone.
In these cases doctors deliver 6,000 to 7,000 units over a seven- to eight-week period. Radiation alone can cure as much as 30 to 40 percent of invasive bladder cancer if it is confined to the bladder and has not spread. Even in cases in which the tumor has spread and cure is unlikely, radiation may be offered to reduce bleeding or relieve pain.
Multidisciplinary Approach for Invasive or Metastatic Bladder Cancer
When bladder cancer is invasive and has extended outside of the bladder (non-organ-confined bladder cancer)—to lymph nodes, for example—multidisciplinary approaches use combinations of surgery, chemotherapy, and radiation. Here, chemotherapy may be given first, followed by surgery. Alternatively, chemotherapy and radiation may be given together, followed by surgery. If a patient is not referred to a medical oncologist until after the surgery, chemotherapy may still be considered, although the benefits are greater when the chemotherapy is given first. This is an example of the ways in which it can be advantageous to begin with a “team” assessment, with consideration of all treatment options, before beginning any treatment.
Chemotherapy is the principle treatment for advanced bladder cancer that is inoperable or bladder cancer that has metastasized. The combination of the drugs methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC), first used in 1983, has been considered the standard treatment.
While very effective in shrinking bladder cancers and helping patients to live longer, this combination has a number of side effects. These include lowering the white blood-cell counts to critically low levels, which makes individuals susceptible to potentially life-threatening infections. The use of growth factors (drugs like granulocyte-colony stimulating factors Neupogen and Neu-lasta) helps the white blood cells to recover faster from chemotherapy and reduces the risk of infection. Other side effects include the risk of toxicity to the heart and kidneys.
There has been significant progress in the use of chemotherapy for bladder cancer, as there are now several new agents being used for treatment. These include the taxanes paclitaxel (Taxol) and docetaxel (Taxotere), gem-citabine (Gemzar), ifosfamide (Ifex), and carboplatin (Paraplatin) or cisplatin (Platinol). These drugs are used in two-drug or three-drug combinations. Combinations like the triplet of paclitaxel, cisplatin, and ifosfamide or the doublets gemcitabine and carboplatin or carboplatin and paclitaxel have shown encouraging results and have manageable side effects.
These less-toxic drug combinations are preferred for patients with bladder cancer who have other significant medical problems, such as frailty or heart or kidney problems, or whose cancer has spread to organs such as the lung, liver, or bones.
Your medical oncologist will carefully weigh the advantages and disadvantages of these different combinations to help you decide on the best options. These two- and three-drug combinations have a number of clinical benefits and are rapidly changing the approach to the use of chemotherapy in bladder cancer. The hope is that we will continue to see improved outcomes with fewer side effects in the future.