Bladder Cancer Treatment Options: Surgery vs. Radiation and Chemotherapy

Q: Bladder Cancer Treatment Options: Surgery vs. Radiation and Chemotherapy

Hello： <br>1) Urinary tract cancers, specifically stage 1 and stage 2, refer to the presence of lesions. <br>Since bladder cancer can be multifocal, some lesions may not have been present three years ago but have developed since then. <br>This is why physicians recommend regular

Is radiation therapy combined with chemotherapy for bladder cancer an option only in place of surgical removal?

Hello Doctor,
I would like to provide a brief overview of my father's condition.
Since I haven't accompanied him to his appointments, some information may not be entirely accurate; I appreciate your understanding.

About eight years ago, my father was diagnosed with ureteral cancer at Kaohsiung Chang Gung Memorial Hospital, where Dr.
Jiang Bo-hui performed surgery to remove one of his ureters.
Since then, he has been living with this condition.
My father has a history of diabetes, and last year or the year before, he experienced symptoms resembling a cold (or possibly kidney-related symptoms, I'm not sure).
Initially, Liu Ying Chi Mei Hospital indicated that he would need dialysis, but after consulting with Dr.
Jiang, he was treated and did not require dialysis.
In March, he was diagnosed with stage II bladder cancer.
At that time, he underwent three or four doses of immunotherapy, each costing around NT$80,000.
He was supposed to receive Bacillus Calmette-Guérin (BCG) therapy, but due to a shortage possibly related to the pandemic, he switched to standard chemotherapy, which seemed to be systemic rather than intravesical.
On May 13, during a follow-up examination, my brother relayed Dr.
Jiang's comments, which may not be entirely precise.
Dr.
Jiang stated, "There are still cancer cells present; it is now stage I.
The bladder needs to be removed, and we need to assess the kidneys." My brother mentioned that Dr.
Jiang seemed to be asking and answering questions himself, and it was unclear whether the kidneys also needed to be removed.
After hearing this, my father was reluctant to have his bladder removed and asked the doctor if there were patients who had successful intravesical treatments.
Dr.
Jiang agreed to try intravesical therapy for another two months.
After hearing my brother's account, I wondered if Dr.
Jiang was accommodating my father's wishes, even though complete removal might be necessary.
Would further intravesical treatment affect his condition?
I would like to ask the following questions:
1.
Is it possible for my father's cancer to have progressed from stage II to stage I after immunotherapy and chemotherapy? Does stage I mean that it has not invaded the muscle layer?
2.
I found information online suggesting that if my father wishes to preserve his bladder, a trimodal approach could be considered, involving resection, chemotherapy, and radiation.
However, I also read in a blog that if radiation therapy is administered, surgery to remove the bladder may not be possible.
Is it a case of having to choose one or the other?
3.
Additionally, I came across a statement online indicating that if there are recurrences every two to three months for over a year, bladder removal should be seriously considered.
However, if the recurrence interval extends to six months or a year, it may be possible to preserve the bladder.
If bladder cancer has not invaded the muscle layer, could it be treated similarly to early-stage liver cancer with ablation? In this case, would it involve resection and intravesical therapy, and could we observe if the recurrence intervals become longer?
Thank you very much, Doctor.

xingfu, 40~49 year old female. Ask Date: 2020/05/21

Dr. Du Shixi reply Urology

Hello:
1) Urinary tract cancers, specifically stage 1 and stage 2, refer to the presence of lesions.
Since bladder cancer can be multifocal, some lesions may not have been present three years ago but have developed since then.
This is why physicians recommend regular follow-ups.
Stage 1 is possible, while stage 2 indicates that there is no invasion of the muscle layer.
2) There are treatment guidelines for bladder cancer (though not every hospital follows them exactly, they are generally similar).
Your family member is different from the average patient because they have a history of ureteral cancer, which increases the likelihood of developing bladder cancer compared to other patients.
Additionally, renal function may not be optimal (though not at the level requiring dialysis) and there is diabetes to consider.
Physicians will propose several treatment options based on the cancer cell differentiation and invasion depth, hospital facilities, and the patient's condition, allowing the patient to choose.
You can refer to this treatment recommendation: http://web.tccf.org.tw/lib/addon.php?act=post&id=3810.
Surgical resection combined with radiation and chemotherapy may be one of the options, but there are also potential side effects, and radiation therapy is managed by radiation oncology, which may have less personal experience.
3) Recurrence multiple times suggests that there may be latent lesions in the bladder mucosa that continue to grow.
Complete cystectomy may be necessary to manage this, but if metastasis occurs, removing the bladder may not lead to a cure.
From the patient's perspective, early aggressive treatment may be difficult to accept and very challenging, but one must also be prepared for the possibility of recurrence.
Wishing your family member good health.

P.S.
If a major surgery is decided upon, hospital physicians will typically gather family members for a meeting to provide clear explanations.

Reply Date: 2020/05/21

More Info

When it comes to bladder cancer treatment, the options can be complex and depend on various factors, including the stage of the cancer, the patient's overall health, and personal preferences. Based on the information you've provided about your father's situation, let's delve into the questions you've raised.

1. Can bladder cancer stage change from II to I after immunotherapy and chemotherapy?
Yes, it is possible for bladder cancer to downstage from a higher stage to a lower stage after treatment. In your father's case, if he was initially diagnosed with stage II bladder cancer and subsequent treatments (immunotherapy and chemotherapy) have shown a reduction in tumor burden, it could potentially be classified as stage I. Stage I bladder cancer typically indicates that the cancer has not invaded the muscle layer of the bladder wall, which is a positive sign. However, the definitive staging would require imaging studies and possibly a biopsy to confirm the absence of muscle invasion.

2. Can bladder preservation strategies be effective?
Bladder preservation strategies, such as the tri-modality approach (which includes transurethral resection of the bladder tumor, chemotherapy, and radiation therapy), can be effective for select patients. However, it's crucial to understand that this approach is typically reserved for patients with non-muscle invasive bladder cancer or those who are not candidates for radical cystectomy due to other health issues.
Regarding your concern about the sequence of treatments, it is generally true that if radiation therapy is administered, it may complicate future surgical options, as radiation can cause changes in the tissue that make surgery more challenging. Therefore, it is essential to have a thorough discussion with your father's oncologist about the best course of action based on his specific circumstances.

3. What about recurrence and treatment decisions?
The recurrence of bladder cancer is a significant concern, and the timing of recurrences can influence treatment decisions. If your father experiences frequent recurrences within a short time frame (e.g., every two to three months), it may indicate a more aggressive disease, and surgical intervention might be warranted. Conversely, if recurrences become less frequent over time, it may suggest a more indolent disease course, allowing for bladder preservation strategies to be considered.

4. Can bladder cancer be treated similarly to early-stage liver cancer?
While there are some parallels in treatment approaches for different types of cancer, bladder cancer and liver cancer are distinct in their management. In liver cancer, techniques like radiofrequency ablation (RFA) can be used for small tumors. In bladder cancer, the standard approach for localized tumors often involves transurethral resection followed by intravesical therapy (such as Bacillus Calmette-Guérin or chemotherapy). The concept of "burning" cancerous tissue is not typically applied to bladder cancer in the same way as it is for liver cancer.

Conclusion
In summary, your father's treatment options should be carefully considered in consultation with his healthcare team. The potential for downstaging after treatment is promising, and bladder preservation strategies may be viable depending on the specifics of his case. However, the decision to pursue surgery, radiation, or a combination of therapies should be made based on a comprehensive evaluation of his cancer's characteristics and his overall health. Regular follow-ups and imaging studies will be crucial in monitoring his condition and guiding future treatment decisions. Always ensure that any treatment plan aligns with the latest clinical guidelines and is tailored to your father's unique situation.

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