What are the treatments for bladder cancer ?
Un traitement personnalisé
Cancer treatment is increasingly personalized.
For each patient, it will depend on various factors collected during the diagnosis and pre-treatment evaluation of the disease: the nature and grade of the cancer cells, the location, and the stage of the disease.
Once bladder cancer has been diagnosed, the primary care physician or urologist who made the diagnosis will often refer the patient to an oncologist specializing in the treatment of these cancers.
The oncologist will not decide alone on the most suitable treatment, as each patient is unique. In practice, each patient's case will be discussed during a Multidisciplinary Consultation Meeting (MCM). This meeting includes at least an oncologist, a radiation therapist, and a urological surgeon.
When a treatment is chosen during the MTBM, the physician who will initially manage the disease, whether an oncologist, urological surgeon, or radiation therapist—will explain in detail the proposed treatment plan during a specific consultation known as the "announcement consultation".
The term "treatment pathway" is indeed appropriate, as the patient will be offered a sometimes-lengthy path marked by several stages. Throughout these stages, one or more of the five available cancer treatments will be used: two of these treatments are local (surgery or radiation therapy), and three are systemic (chemotherapy, targeted therapy, or immunotherapy). Chemotherapy and targeted therapies are administered orally or intravenously to reach cancer cells that may have spread. Immunotherapies are given intravenously to stimulate the immune system cells so that they can eliminate cancer cells.
Some treatments, whether radiation therapy, chemotherapy, targeted therapy, or immunotherapy, can be administered alone or in combination before surgery and are called neoadjuvant treatments. If prescribed after surgery, they are known as adjuvant treatments.
Surgery is often the initial treatment for bladder cancers.
Treatment of non-muscle-invasive bladder cancer
Initial treatment
For patients with non-muscle-invasive bladder tumors, the tumor tissue is removed from within the bladder through transurethral resection of the bladder (as previously described in the Diagnostic section).
In these patients, adjuvant treatment with chemotherapy or local immunotherapy will be administered after transurethral resection of the bladder.
The aim of this treatment is to significantly reduce the risk of recurrence. It is performed by instilling chemotherapy or local immunotherapy directly into the bladder. For this instillation, a thin urinary catheter is introduced into the urethra, and the medication is injected directly into the bladder. These drugs block the multiplication of tumor cells. Local immunotherapy is carried out by instilling Bacillus Calmette-Guérin (BCG).
Expert perspective
BCG is commonly used for tuberculosis vaccination. Since 1976, it has been prescribed to reduce recurrences of non-muscle-invasive bladder cancer. The exact mechanism of BCG's action is not entirely clear, but it is believed to locally stimulate the immune system to reject tumor cells. BCG is instilled 4 to 6 weeks after tumor resection and is effective in 60% to 70% of cases (source: arcagy.org).
Treatment in case of recurrence
When early recurrence of cancer is observed in these patients, a surgical intervention will initially involve removing the bladder (cystectomy).
Cystectomy is accompanied by a lymphadenectomy, which involves removing the lymph nodes in the pelvis that may have been invaded by tumor cells. The uterus in women and the prostate in men may also be removed.
In a second phase, the surgical procedure includes the installation of a diversion system to replace the bladder and to allow for the drainage of urine produced by the kidneys.
đź’ˇ DID YOU KNOW ?
Three types of urinary diversion are considered based on the patient's situation.
- Ileal Neobladder : An artificial bladder is constructed from a segment of the intestine ( the ileum ). The segment of intestine is shaped by the surgeon to create a reservoir. It is then connected to the ureters (tubes carrying urine from the kidneys) and the urethra (tube allowing urine to be expelled during urination). This neobladder, implanted inside the abdomen, allows for urine to be expelled through natural pathways.
- Continent Cutaneous Diversion : This method involves creating a new reservoir from a segment of the intestine, similar to the ileal neobladder. However, this reservoir is not connected to the urethra for natural urine expulsion. Instead, it is connected via a tube to a skin opening, allowing the patient to perform regular manual drainage (every 6 hours).
- Bricker Uretero-Ileal Diversion : The surgeon removes a segment of the intestine and connects it to the kidneys via the ureters. This segment is then connected to the skin near the navel, and the end of the segment appears as a visible opening on the abdomen (stoma). It serves as a support for an external urine collection bag, which is affixed to the body. The patient must then learn to empty and change this bag regularly (source: chu-lyon.fr).
The choice of diversion type depends on factors such as the patient’s age, kidney function, and tumor characteristics. The patient should be clearly informed about the advantages and disadvantages of each option, so that a decision shared between the physician and patient can be made in the patient's best interest.
The surgical procedure can be performed via laparotomy (incision below the navel) or laparoscopically, with or without robotic assistance.
Expert perspective
Laparoscopy
, also known as
celioscopy
, requires only small incisions in the abdomen.
These incisions allow for the insertion of a thin, flexible tube equipped with a fiber-optic camera ( endoscope ) to visualize the area to be operated on in two dimensions (2D). They also allow for the introduction of small instruments to remove tumor areas.
Laparoscopy can also be performed using a robot ( robot-assisted laparoscopy ). The robot controls four surgical arms positioned above the patient. The surgeon views the organs in high definition (HD) and three dimensions (3D) and manipulates the robotic arms with great precision to remove the targeted organs.
Regardless of the technique used, the surgical procedure is performed under general or epidural anesthesia. Robotic surgery yields similar results to non-robotic laparoscopy and reduces the length of hospital stay.
Treatment of muscle-invasive bladder cancer
This surgical procedure, which includes cystectomy, lymphadenectomy, and the placement of a diversion system, is performed initially in patients with muscle-invasive bladder tumors.
In these patients, when the tumor is particularly large, neoadjuvant chemotherapy may be administered before the surgical intervention to reduce the tumor size.
TO REMIND YOU
Chemotherapy aims to kill cancer cells, regardless of their location in the body.
It works by targeting all rapidly dividing cells, such as cancer cells. However, some normal cells also divide rapidly, such as blood cells, cells in hair follicles (which produce hair), and cells lining the digestive tract. Damage to these normal cells can cause the side effects associated with certain chemotherapies.
Before starting chemotherapy, biological tests will be performed to check that the counts of red blood cells (which transport oxygen to various tissues), white blood cells (which are involved in immune defense), and platelets (which are involved in blood clotting) are normal.
These counts can decrease during chemotherapy and will be monitored throughout the treatment. Additionally, the absence of infections, including dental infections, will be checked.
Chemotherapy is usually administered as a combination of several drugs. In practice, these drugs are often given through an intravenous infusion lasting about 3 hours. To facilitate these infusions, a port may be implanted in the patient. This port is a small reservoir placed under the skin below the collarbone. From this reservoir extends a thin, flexible tube (catheter) that goes into a large vein. Medications are injected directly into the port, which is more comfortable for the patient compared to infusions administered through a peripheral vein.
Chemotherapy may also be prescribed as an adjuvant treatment after surgery to prevent recurrences and metastases or in cases of very advanced or metastatic cancer.
Radiotherapy
Another treatment for bladder cancer is external radiation therapy.
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In external beam radiation therapy, a machine delivers radiation through the skin to the tumor and some surrounding tissue. The radiation gradually destroys cancer cells. Radiation oncologists target the smallest possible area to minimize the risk of side effects.
External beam radiation therapy is not used alone but in combination with chemotherapy, especially when the goal is to preserve the bladder in patients with muscle-invasive bladder cancer.
In these cases, a deep and complete transurethral resection of the bladder tumor is performed first. This resection is followed by external beam radiation therapy. Simultaneously, chemotherapy using a combination of three drugs is administered. This approach, involving resection followed by radiation therapy and concurrent chemotherapy, constitutes a trimodal treatment. </.box>
Immunotherapy
For patients with advanced or metastatic disease, checkpoint inhibitor immunotherapies represent a significant advancement.
Expert perspective
The use of
immunotherapy with checkpoint inhibitors
represents a significant breakthrough in the treatment of certain cancers, including bladder cancer.
These treatments are based on three key discoveries :
- Discovery of checkpoint molecules : specific molecules known as checkpoints can either accelerate or slow down the immune system's activity ;
- Cancer cells' use of checkpoints: cancer cells can exploit checkpoints to evade the immune system. For instance, a checkpoint molecule called PD-L1 , present on the surface of cancer cells, binds to another molecule called PD-1 found on the surface of cytotoxic T lymphocytes , which are immune cells responsible for killing cancer cells.
- The binding of PD-L1 to PD-1 inhibits the T lymphocytes from performing their role, allowing the cancer cells to avoid destruction. Effectiveness of checkpoint inhibitors: drugs that block the PD-1 or PD-L1 checkpoints can reactivate the immune system to target and eliminate cancer cells. Unlike chemotherapy, which directly destroys cancer cells, these immunotherapies work by stimulating the immune system to attack the cancer cells.
These therapies are often more effective when cancer cells have a high amount of PD-L1 on their surface.
Currently, five immunotherapies targeting PD-1 or PD-L1 checkpoints are used for treating locally advanced or metastatic bladder cancer. These immunotherapies are utilized as maintenance treatment after chemotherapy or for treating bladder cancer that recurs after chemotherapy. They may also be used as first-line treatment for patients who cannot tolerate platinum-based chemotherapy. Additionally, these immunotherapies may soon be used in neoadjuvant settings, potentially allowing bladder preservation in some patients with muscle-invasive bladder tumors2.
Targeted therapies
For patients with metastatic bladder cancer, new treatments have been developed, including targeted therapies.
đź’ˇ DID YOU KNOW ?
As their name suggests, targeted therapies specifically focus on molecules involved in transforming normal cells into cancerous cells or in the development of malignant tumors. Unlike chemotherapy drugs, which broadly inhibit the proliferation of cancer cells, targeted therapies aim at the specific mechanisms underlying the cancerous transformation of cells.
Antibody drugs
Among the new treatments, two belong to a novel class of drugs known as antibody-drug conjugates (ADCs).
Expert perspective
Antibodies are Y -shaped molecules naturally produced by certain cells in the immune system. The tips of the two small arms of the Y can precisely recognize a target, such as a microbe or cancer cell, to eliminate it. Artificially manufactured antibodies are used as medications.
Some antibodies are used alone, for example, to target and block a growth factor for tumor cells, serving as targeted therapy .
Other antibodies are used alone to target and block an immune checkpoint, serving as immunotherapy (see the section on checkpoint inhibitor immunotherapies).
A new class of cancer drugs involves coupling an antibody with a drug that kills cancer cells . The antibody targets a molecule present on the surface of cancer cells and delivers the drug that destroys the tumor cells.
Clinical trials
Ultimately, physicians are constantly seeking to improve the management of patients with bladder cancer. To achieve this goal, they conduct clinical trials. Patients participating in these trials benefit from the latest research advancements and become true partners with the physicians conducting these trials, contributing to new progress.
Discover clinical trials in bladder cancer (coming soon)
2 Klemm, J., Laukhtina, E. & Shariat, S. F. Combination neoadjuvant therapies are paving the way for bladder preservation to become the standard for selected patients. Nat Rev Clin Oncol 21, 87–88 (2024).
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Article updated on Jan 20, 2025
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