If you’ve been diagnosed with advanced bladder cancer, you’ll probably see several doctors, such as a urologist, an oncologist, a surgeon, and a radiotherapist, to start treatment. A dietitian and others can help you with recovery.
At the first appointment, a rectal exam will likely be done; for women, a pelvic exam may also be performed.
Urine and blood samples will be checked for cancer cells, among other things. “Bladder cancer can cause blood in the urine, which may lead to clots that can block your urethra and cause pain,” says Soroush Rais-Bahrami, M.D., assistant professor of urology at the University of Alabama at Birmingham School of Medicine. If your doctor suspects such a blockage, they may order imaging tests to verify and locate it. In a test called a cystoscopy, your doctor inserts a thin, lighted tube with a lens through your urethra and into your bladder to see if there are any unusual growths. You may be given local anesthesia for this procedure.
If the cystoscopy reveals abnormal tissue, there will be further testing. The first step, says Dr. Rais-Bahrami, “is often a transurethral resection of bladder tumor (TURBT),” which is used to diagnose bladder cancer, as well as to treat superficial forms of the disease.
Bladder cancer that’s considered “advanced” covers a range of stages and types. If your cancer has not been staged, you will be tested to see how far along it is. If your cancer has been treated, you will be monitored for returning cancer cells, typically with a CT (computerized tomography) scan or MRI (magnetic resonance imaging). Newer and highly accurate imaging techniques include a multiparametric MRI or a specialized positron emission tomography scan.
CHEMOTHERAPY. Intravenous chemotherapy is the first-line treatment for muscle-invasive bladder cancer and bladder cancer that has spread to lymph nodes or other organs. It is designed to slow or stop the growth of cancer cells by interfering with their ability to divide and reproduce. Sometimes, chemotherapy is given before bladder-removal surgery.
SURGERY. Localized muscle-invasive bladder cancer can be treated with chemotherapy and surgery to remove the bladder, a procedure called radical cystectomy. When a person’s bladder is taken out, a new way to store and remove urine from the body must be created. There are a few ways to do this. Urine can be diverted through a segment of the intestine to the skin’s surface, where a bag collects the urine at the opening (called a stoma). Alternatively, surgeons can create a pouch under the skin that drains urine out through a catheter. Another option is to get an entirely new bladder (neobladder) created from a piece of intestine and connected to the urethra to enable normal urination.
RADIATION THERAPY. Sometimes, high-energy radiation is used to destroy cancer cells in people with advanced bladder cancer. It can be part of initial treatment along with chemotherapy, for example, or used to treat pain or other symptoms. The type most often used for bladder cancer is called external beam radiation.
IMMUNOTHERAPY. If chemotherapy stops working or can’t be given safely, immunotherapy drugs may be used to help your immune system identify and attack cancer cells. Two of these drugs—atezolizumab (Tecentriq) and pembrolizumab (Keytruda)—have become first-line treatments for people with advanced bladder cancer who can’t have cisplatin-based chemotherapy because of other health problems, and whose tumors contain high levels of the protein PD-L1. These drugs are administered intravenously.
TARGETED THERAPY. For adults with advanced bladder cancer who have a specific genetic mutation (FGFR3 or FGFR2), a new drug, erdafitinib (Balversa), that targets these mutations may be an option.
AFTER TREATMENT, you may see your oncologist or urologist for ongoing follow-up care, though some people see their primary care doctor. Generally, experts recommend checkups every three to six months for the first three years, and yearly after that, but ask your doctor for specifics.