BLADDER CANCER RELATED PATIENT QUESTIONS
Questions answered about :
TURBT, Intravesical BCG tolerating problem, Intravesical Mitomycin,
Ileal Conduit Urine leaking problem,
Chemotherapy need before/ after Radical Cystectomy
Prognosis, Survival figures after Radical Cystectomy
Radiotherapy and chemotherapy - What is involved in this treatment
Survival figures after Radical Radiotherapy for T3,T2 bladder cancer
1) I had a bladder tumor resected via telescope (Trans-Urethral Resection of Bladder Tumor ~ TURBT) for the first time 4 weeks ago and told to have pT1 G3 cancer of the bladder. Why am I having a second operation (TURBT) within 4 weeks of the first?
Mr.Varadaraj - For high grade bladder cancer (grade 3) and carcinoma-in-situ a second look TURBT is undertaken, as there is 4 to 10% chance of the tumor being upstaged to show involvement of the bladder muscle, which will require a more radical treatment like radical cystectomy or Radiotherapy instead of intravesical BCG treatment option. It has been demonstrated that a second TURBT within 4 weeks with further resection around and through the base of the original tumor can remove any residual tumor and reduces recurrence and improves prognosis in high grade bladder cancer.
2) I am on the 6 monthly intravesical BCG maintenance (at 12 months stage now) and getting the weekly once instillation for 3 weeks. I have severe urgency, frequency, bladder discomfort after the first two instillation now and anticholinergics tablets to slow the bladder, has not been of much help. There is no blood in the urine after the instillations or urinary tract infection but I have fever which settles in 48 hours. The severe bladder symptoms, fever were similar after every maintenance instillation previously and took a while to settle. I am considering the option of dropping out of the maintenance treatment. Is there any alternative?
Mr.Varadaraj - Many studies have shown reducing the BCG maintenance dose to one third is equally effective with less side effects and is followed in USA in few centres. In UK however due to current guidelines relating to intravesical BCG and risk of infection with live tubercle bacilli at the time of reconstitution, it is not permissible to dilute the reconstituted standard intravesical BCG 81mg dose in any alternative way to calibrate the reduced final dose (a complex process).
There are two alternatives available which can be tried instead of dropping out of the maintenance BCG treatment.
The First option is to decrease the dwell time or the time the BCG solution is left in your bladder from the standard 2 hours duration down to 30 minutes. The decreased duration of BCG contact with the bladder lining helps to reduce the adverse effects without affecting efficacy (long term results awaited) and this may represent a treatment alternative for patients with BCG intolerance 1, 2
The second option is to consider the use of two doses of antibiotic Ofloxacin 200mg with the first dose administered 6 hours after first urination after intravesical BCG and the second dose 12 hours after the first dose. Ofloxacin has tuberculostatic properties, excreted in active form in the urine and therefore may decrease the prolonged action of the BCG on the bladder leading to a decrease in the adverse events 3, 4
Please discuss your problem with the Urology Specialist Nurse who looks after your intravesical instillations or your Consultant Urologist for the possible options before your decide to discontinue treatment.
3) A gentleman I know who has bladder tumor is getting intravesical BCG. I have been offered intravesical Mitomycin chemotherapy for a recurrent small multisite grade 1, pTa bladder cancer. Why have I not been offered intravesical BCG as I understand it is more effective?
Mr.Varadaraj - For recurrent or small superficial multiple tumors with grade 1, pTa bladder cancer intravesical mitomycin is effective in reducing the recurrence of such bladder tumors and is preferred to BCG in the first instance. It is administered as one instillation into the bladder once every week for 6 or 8 weeks. If there is recurrence of the bladder cancer after intravesical mitomycin full course and your tumor grade & stage increases, intravesical BCG will be considered 5 Intravesical BCG immunotherapy is primarily used for high grade (G3) bladder cancer including carcinoma-in-situ, intermediate risk bladder cancer and has been shown to be superior to intravesical mitomycin chemotherapy in preventing recurrence of the cancer and progression to muscle invasive bladder cancer. However it is important to be aware that intravesical BCG is associated with significant bladder and systemic side-effects/toxicity compared to intravesical mitomycin.
4) After my ileal conduit urinary diversion 2 weeks ago my urinary stoma bag is leaking regularly at night and making it frustrating to manage and I have to change clothes constantly due to urine leak. Any solution for this?
Mr.Varadaraj - You can always connect your stoma bag to a urine drainage/collection "thigh" or "leg" bag. This will enable the urine to keep draining and collecting in the drainage bag which has got a non-return mechanism. When the stoma bag is not adherent properly to a small area on the skin, urine starts to leak from here when the stoma bag fills up ,especially when you are lying down. Connecting it to a drainage bag will prevent the stoma bag from filling up and leaking urine. You can contact your Stoma Nurse or Urology Specialist Nurse for further advise if needed and discuss about the short term use of a stoma appliance with a belt to ensure a snug fit of the stoma bag around the ileal conduit or any alternative they may advice.
5) I have muscle invasive T2G3 bladder cancer. I am due to have chemotherapy before my bladder removal surgery/cystectomy. Will this chemotherapy help me and will I be fit for the surgery after the chemotherapy.
Mr.Varadaraj - Chemotherapy before your sugery to remove your bladder (Radical Cystectomy) is referred to as neo-adjuvant chemotherapy. Advantage - Many studies involving hundreds of patients have shown that neo-adjuvant cisplatin-containing combination chemotherapy improves overall survival by 6% at 5 years and is recomended in current Guidelines. This means 50 out of 100 patients who recieve the neo-adjuvant chemotherapy will get benefit and will live to 5 years after Cystectomy or Radiotherapy compared to 44 out of 100 patients who dont receive the chemotherapy. Depending on the stage of the bladder cancer and its agressive nature the survival figures vary and can be longer. The answer to your question is "yes you may benefit from your chemotherapy". Many a times if the response to neo-adjuvant chemotherapy is good there is no residual tumor found in the bladder when it is removed. Neo-adjuvant chemotherapy treats any micrometastasis in lymph nodes and decreases the risk of recurrence. Most patients tolerate neo-adjuvant chemotherapy well. Neo-adjuvant chemotherapy is much better tolerated compared to receiving adjuvant chemotherapy after your cystectomy. Radical cystectomy is still considered the gold standard for treatment of invasive bladder cancer localised to the bladder.
Disadvantages - (i) The intent of neo-adjuvant chemotherapy is to treat any microscopic spread of the disease outside the bladder. However there is no current technology available which will answer if this chemotherapy is overtreatment in patients without any spread and avoidable considering the significant side effects of the combination chemotherapy.
(ii) The major disadvantage of neo-adjuvant chemotherapy is the delay in treatment with a cystectomy or Radiotherapy in patients in whom the cancer cells do not respond or the cancer progresses despite chemotherapy. It is difficult to predict if the bladder cancer will respond to a particular type of combination of two or more chemotherapy medication. With neoadjuvant chemotherapy (three cycles) given over six weeks followed by a mandatory period to recover of up to six weeks (to prevent toxic side-effects persisting) there is a delay in the definitive treatment of cystectomy or radiotherapy by atleast 12 weeks or more. In such a scenario if the definitive treatment is delayed the long term outcome is poorer, meaning the cancer may come back earlier or spread due to the delay in surgery or radiotherapy.
If your general health (referred to as performance status) is not good or if you have renal failure, you will not be eligible for neo-adjuvant chemotherapy. Therefore this type of chemotherapy in bladder cancer is used in a selected patients.
6) I have undergone a Radical Cystectomy for muscle invasive high grade bladder cancer with pelvic lymph node dissection a few weeks ago. I have been informed that my histological/Pathological stage(p) is pT3a,N2 cancer. My preoperative scan had not shown any spread/metastasis or any significant pelvic lymph nodes. Considering the cancer has spread to my pelvic lymph nodes and there is no obvious metastasis (M0) is there any role for chemotherapy after the surgery? I have been informed that I will not be having chemotherapy as it is not standard part of the treatment after my radical cystectomy.
Mr.Varadaraj - Chemotherapy after surgery is referred to as "adjuvant" chemotherapy. Adjuvant chemotherapy for Bladder Cancer following Radical Cystectomy with pT3/4 and/or lymph node positive (N+) disease without clinically detectable metastases (M0) is under debate. Neither randomized trials nor a meta-analysis (complex result analysis of many studies/trials where hundreds of patients have either had or did not have a particular type of treatment) have provided sufficient data to support the routine use of adjuvant chemotherapy in bladder cancer. Unless there is an ongoing clinical trial for adjuvant chemotherapy for bladder cancer where a patient can be referred, this form of treatment is not provided as standard treatment based on current guidelines. Also from the evidence available so far, it is unclear whether immediate adjuvant chemotherapy or chemotherapy at the time of recurrence of the bladder cancer is superior as far as cancer specific survival benefit is concerned. Adjuvant chemotherapy for example with Cisplatin and Methotrexate have significant side effects, which may be detrimental, especially when it is given when you are just recovering from a major surgery, like your cystectomy. Pelvic lymph node dissection provides a good clearance of the cancer in the nodes and is the best option currently, if the tumor has not spread beyond the pelvic lymph nodes. However a review of adjuvant chemotherapy series (called cochrane review) suggested that 54 out of every 100 patients who had chemotherapy after surgery were alive after three years, compared to 45 out of every 100 patients who received only surgery. Although these results are encouraging, there are not enough trials or patients for these results to be completely reliable6. The decision about your treatment would have been taken after discussion of your medical history, current health status, histology details etc at your local Multi-disciplinary team (MDT) meeting by the Urologists and Oncologists together. Some details of bladder cancer research and trials are available at this Link.
RADIOTHERAPY FOR BLADDER CANCER
8) My Father is due to have radiotherapy (high intensity x-ray) treatment to the bladder as his cancer has invaded the bladder muscle and is not suitable for surgical removal of the bladder (cystectomy). What does the radiotherapy treatment comprise of? They also mentioned chemotherapy before the radiotherapy and we are waiting to meet the oncologist next week.
Mr.Varadaraj - The chemotherapy treatment before radiotherapy (referred to as neo-adjuvant chemotherapy) may be different between hospitals/ centres. To give you a rough idea, at our centre there are two chemotherapy medication/drugs used before the start of radiotherapy - Gemcitabine & Cisplatin. There are 3 cycles of chemotherapy (each over a week) and is given over 3 weeks on an outpatient basis as follows: week 1 - Day 1 Gemcitabine & Cisplatin through a cannula in the vein as a drip over a 6 hour period , Day 2 Gemcitabine only over 2 hours. The same regimen is repeated the 2nd and 3rd week.
This is followed by a CT Scan of the bladder to plan the radiotherapy treatment. Radiotherapy treatment visits will be for about 20 minutes to the hospital on an outpatient basis. The actual radiotherapy treatment will be for about 5 minutes and will involve lying on a special xray table for this duration. The radiotherapy treatment will be usually from Monday to Friday, over 6 & a half weeks comprising of 32 sessions in total (5 sessions in a week).
Your oncology consultant will give you the exact details at the time of consultation about the chemotherapy drugs, combination that will be used and the total radiotherapy dose broken down into sessions. The number (combination) of chemotherapy drugs and if they will be given before or during the radiotherapy sessions will depend on which trial the patient will be enrolled into. There are many trials looking at chemotherapy+ Radiotherapy as the treatment option for muscle invasive bladder cancer.
9) What is the Radical Radiotherapy survival figures for muscle invasive bladder cancer ?
Mr.Varadaraj - In clinical stage T3 and T2 disease, external beam radical radiotherapy is associated with a 5-year survival rate of 20%-50% Ref. With neo-adjuvant chemotherapy and newer modalities of Radiotherapy these survival rates may improve and results from trials are awaited. If there is recurrence following radiotherapy one of the option, if the patient is fit for surgery, is salvage cystectomy.