| FEATURE |
Muscle Invasive Bladder Cancer
About 800,000 people today are living with bladder cancer in the United States. For about one-fourth of these patients, the cancer has spread into the muscle of the bladder. This is known as muscle invasive bladder cancer.
While treatment for this type of bladder cancer is more complicated than cancer that has not yet spread into the muscle of the bladder, many patients are able to have full and productive lives, according to Sumeet Bhanvadia, MD, Assistant Professor of Clinical Urology at the University of Southern California.
What is Muscle Invasive Bladder Cancer?
Most bladder cancers begin in the inner lining of the bladder. Over time, if it is not treated, the cancer may grow outside the bladder into nearby tissues. In some cases, it can spread into other parts of the body.
Bladder cancer is most often found in people over 70. Men are three times as likely as women to develop the disease. It is more common in Caucasians, but African-Americans are less likely to survive the disease.
Blood in the urine and burning when urinating are the most common signs of bladder cancer. Blood in the urine may also be a sign of an infection or kidney stones. “Sometimes the diagnosis of bladder cancer is delayed in women because it is assumed to be a urinary tract infection (UTI),” Dr. Bhanvadia noted. In some cases, a person will be diagnosed with bladder cancer after microscopic amounts of blood are discovered in the urine during a routine urine test.
To diagnose bladder cancer, the doctor will use a cystoscope—a thin tube with a light and camera at the end of it. The tube passes through the urethra (the tube that brings urine from the bladder to outside the body) into the bladder. The doctor will use this tool to take a tissue sample.
Preventing Muscle Invasive Bladder Cancer
The biggest risk factor for bladder cancer is smoking. “Not smoking is the best way to prevent any type of bladder cancer,” Dr. Bhanvadia said. “Even if you smoke now, quitting will decrease the risk of bladder cancer, and increase the chance of a good outcome if you do have the disease. People who don’t currently smoke may have better responses to chemotherapy, have fewer complications after surgery, and overall, have a better quality of life after treatment.”
Certain types of chemical exposures during work may also increase the risk of bladder cancer. These include chemicals used to make plastics, paints, textiles, leather and rubber.
For patients who already have bladder cancer, the best way to decrease the risk of the disease spreading to the muscle is to follow your urologist’s recommendation for treatment of your disease, Dr. Bhanvadia said.
Treatment for Muscle Invasive Bladder Cancer
The standard treatment for muscle-invasive bladder cancer is chemotherapy, followed by a surgical procedure called radical cystectomy. Some people whose cancer has spread into the muscle, but not into other parts of the body, can be treated with chemotherapy and radiation. The type of treatment a person receives depends on how much the cancer has grown.
There are two types of bladder surgery: open or robotic. With open surgery, the doctor makes a large cut in the middle of the abdomen to remove the bladder. With robotic surgery, the surgeon uses computers to help during the procedure. A few smaller cuts are made in the abdomen. The doctor puts small instruments through the openings to reach the bladder.
In both types of procedures, the surgeon will remove the entire bladder, nearby lymph nodes and part of the urethra. In men, the prostate will also be removed.
Because the bladder is removed, the surgeon has to make another way for urine to be collected from the kidneys and stored before it passes out of the body. This is called urinary diversion. There are three types of urinary diversion:
Ileal conduit: The surgeon takes a piece of the small intestine to create an opening (called a stoma) on the surface of the stomach. The ureters, which are the tubes that connect the kidney to the bladder, are plugged up. This forces the urine to leave the body through the opening. The patient wears a bag to store the urine, which has to be dumped out several times a day. “The downside is the patient has to wear a permanent bag,” Dr. Bhanvadia said. “For patients with compromised kidney function and for some elderly patients, this may be the only reasonable option.”
Neobladder: The surgeon creates a new bladder inside the body by taking a longer segment of the small intestine and reconstructing it into a pouch to store urine. The ureters are connected to the pouch, and the patient empties urine through the urethra. “This option can cause leaking and retention of urine,” said Dr. Bhanvadia. “At our institution, patients with a neobladder start physical therapy before surgery, and continue afterward, to learn to urinate somewhat naturally.”
Continent cutaneous reservoir: The surgeon creates a pouch inside the body with a channel connected to the belly button. The patient learns to use a small plastic catheter to remove urine through the belly button. “This is the most complex type of urinary diversion to create, and is the hardest for patients to manage,” Dr. Bhanvadia said. “But there’s no concern about urine leakage, so it’s a good solution for some people.” She said this procedure should only be done at medical centers with a lot of experience in creating this type of urinary diversion.
Promising New Treatment
For some patients whose cancer has spread beyond the bladder, or whose muscle-invasive bladder cancer has returned, a new immunotherapy treatment may help. Immunotherapy is a type of cancer treatment that uses the body’s natural defenses to identify, attack and kill cancer cells. For muscle invasive bladder cancer, a type of immunotherapy called a PDL1 inhibitor is showing promising results. “Previously we had very few options for these patients,” Dr. Bhanvadia said. “This is giving us a lot of hope.”
After treatment, many patients successfully adapt to whatever type of urinary diversion they have chosen, and can resume many, or most, of their daily activities, Dr. Bhanvadia said. “Our goal is to get patients back to as close to the quality of life as they had beforehand,” she said. “Muscle-invasive bladder cancer is an aggressive disease, and we focus on beating it. But we also spend a lot of time focusing on helping patients get back to their regular lives.”
Many patients find it helpful to get support from other people who have gone through the same surgery. The Bladder Cancer Advocacy Network offers support groups and patient blogs.
After treatment, the doctor will let you know how often you need to come back for checkups and testing (such as CT scans and lab tests). “You may be asked to come back often for appointments, and it’s very important that you do,” Dr. Bhanvadia said. “Regardless of the stage of bladder cancer you are diagnosed with, the most important thing is to understand that while treatment and follow-up may be intense, following the recommendations of your doctor is a powerful predictor of how well you will do.”
Listen to our podast below, What to Know about Muscle Invasive Bladder Cancer (MIBC), or go online to UrologyHealth.org/urologic-conditions/muscle-invasive-bladder-cancer.
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UrologyHealth.org | FALL 2020 | UROLOGYHEALTH extra