Treatment for bladder cancer depends on the stage of the disease (particularly if, or how deeply, the cancer has invaded the bladder wall), the grade of the cancer, the patient's general health, and other factors. People with bladder cancer are often treated by a team of specialists, which may include a urologist, oncologist, and radiation oncologist. The doctors develop a treatment plan to fit each patient's needs. Depending on its stage and grade, bladder cancer may be treated with surgery, radiation therapy, chemotherapy, or biological therapy. Doctors may recommend one treatment method or a combination of methods. It is important for patients to discuss the treatment plan with their doctors.

Some patients take part in a clinical trial (research study) using new treatment methods. Such studies are designed to improve cancer treatment.

Getting a Second Opinion

Before starting treatment, the patient may want a second specialist to review the diagnosis and the treatment plan. It may take a week or two to arrange for a second opinion. A short delay will not reduce the chance that treatment will be successful. Some insurance companies require a second opinion; others may cover a second opinion if the patient requests it.

There are a number of ways to find a doctor who can give a second opinion:

• The patient's doctor may be able to suggest specialists to consult.
• The Cancer Information Service, at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute.
• Patients can get the names of doctors from their local medical society, a nearby hospital, or a medical school.
• The Directory of Medical Specialists lists doctors' names along with their specialty and their background. This resource is in most public libraries.

Preparing for Treatment

Many people with cancer want to learn all they can about the disease and their treatment choices so they can take an active part in decisions about their medical care. When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult to think of everything to ask the doctor. Often, it helps to make a list of questions. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some people also want to have a family member or friend with them when they talk to the doctor--to take part in the discussion, to take notes, or just to listen.

People do not need to ask all of their questions or remember all of the answers at one time. Questions may arise throughout the treatment process. Patients may ask doctors, nurses, or other members of the health care team to explain things further or to provide more information.

These are some questions a patient may want to ask the doctor before treatment begins:

• What is the diagnosis?
• What is the stage of the disease?
• What is the grade of the disease?
• What are the treatment choices? Which do you recommend? Why?
• What are the risks and possible side effects of each treatment?
• What are the chances that the treatment will be successful?
• What new treatments are being studied in clinical trials? Would a clinical trial be appropriate?
• How long will treatment last?
• Will treatment affect my normal activities? If so, for how long?
• What is the treatment likely to cost?

Methods of Treatment

Surgery is a common form of treatment for bladder cancer. Early (superficial) bladder cancer may be treated at the time of diagnosis through a procedure called transurethral resection (TUR). During TUR, the doctor inserts a cystoscope into the bladder through the urethra. The doctor then uses a tool with a small wire loop on the end to remove the cancer or to burn away cancer cells with an electric current (fulguration). TUR requires anesthesia and may be done in the hospital.

Surgery to remove part or all of the bladder is called cystectomy. The most common form of surgery for invasive bladder cancer is radical cystectomy. This surgery may be done when the bladder cancer invades the muscle wall, or when superficial cancer involves a large part of the bladder.

Radical cystectomy removes the entire bladder, nearby lymph nodes, and any surrounding organs that contain cancerous cells. In men, the nearby organs that are removed are the prostate and the seminal vesicles. In women, the uterus, the ovaries, and part of the vagina are removed. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to relieve urinary symptoms caused by the cancer. When the bladder must be removed, the doctor creates another way for urine to leave the body. (See Side Effects of Treatment and Rehabilitation).

In some cases, patients may have part of the bladder removed in an operation called segmental cystectomy. This type of surgery may be done when a patient has a low-grade cancer that has invaded the wall of the bladder but is limited to one area of the organ. Because most of the bladder remains intact, a patient urinates normally after recovering from this surgery.

These are some questions a patient may want to ask the doctor before surgery:

• What kind of operation will it be?
• Will I need more treatment after surgery? What kind?
• How will I feel after the operation?
• If I have pain, how will you help?
• Will I urinate in a normal way?
• How will surgery affect my normal activities?

In radiation therapy (also called radiotherapy), high-energy rays are used to kill cancer cells. Like surgery, radiation therapy is local therapy; it affects cancer cells only in the treated area. Sometimes, radiation is given before or after surgery or along with anticancer drugs. When bladder cancer has spread to other organs, radiation therapy may be used to relieve symptoms caused by the cancer.

Radiation may come from a machine outside the body (external radiation) or from a small container of radioactive material, called a radiation implant, placed directly into the bladder (internal radiation). Some patients have both kinds of radiation therapy.

External radiation therapy is usually given on an outpatient basis in a hospital or clinic 5 days a week for 5 to 7 weeks. Treatment may be shorter when external radiation is given along with radiation implants.

These are some questions a patient may want to ask the doctor before having radiation therapy.

• What is the goal of this treatment?
• How will the radiation be given?
• What type of treatment schedule will I follow?
• How will I feel during therapy?
• What can I do to take care of myself during therapy?
• How will we know if the radiation is working?
• When will I be able to resume my normal activities?

For internal radiation, radiation implants are placed in the bladder either through the urethra or during surgery. The patient stays in the hospital for several days while the implant is in place. To protect others from exposure to radiation, patients may not be able to have visitors or may have visitors for only a short time. Once an implant is removed, there is no radioactivity in the body.

Chemotherapy is the use of drugs to kill cancer cells. The doctor may use one drug or a combination of drugs. Chemotherapy may be used alone or after TUR with fulguration to treat superficial bladder cancer. In a treatment called intravesical chemotherapy, anticancer drugs are placed in the bladder through a tube called a catheter, which is inserted through the urethra. When given in this way, the anticancer drugs, which remain in the bladder for several hours, affect mainly the cells of the bladder. The treatment is usually done once a week for several weeks. Sometimes, the treatments continue once or several times a month for up to a year.

Chemotherapy also may be used to help control the disease when cancer cells have deeply invaded the bladder or spread to lymph nodes or other organs. In this case, the anticancer drugs are usually given by injection into a vein (IV); some may be given by mouth. This form of chemotherapy is systemic therapy, meaning that the drugs flow through the bloodstream to nearly every part of the body. The drugs are usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Chemotherapy may be used alone or in combination with surgery or radiation therapy.

These are some questions patients may want to ask the doctor before starting chemotherapy:

• What is the goal of this treatment?
• What drugs will I be taking?
• Will the drugs cause side effects? What can I do about them?
• How long will I need to take this treatment?
• What can I do to take care of myself during treatment?
• How will I know if the drugs are working?

Usually a patient has chemotherapy as an outpatient (at the hospital, at the doctor's office, or at home). However, depending on which drugs are given and the patient's general health, a short hospital stay may be needed.

Biological therapy (also called immunotherapy) is a form of treatment that uses the body's natural ability (immune system) to fight cancer. Biological therapy for bladder cancer is most often used when the disease is superficial. Like chemotherapy, biological therapy may be used alone to treat bladder cancer or after TUR with fulguration to help prevent the cancer from recurring. This form of treatment involves placing a solution of BCG, a substance that stimulates the immune system, into the bladder. The medicine stays in the bladder for about 2 hours before the patient is allowed to empty the bladder by urinating. This treatment is usually done once a week for 6 weeks and may need to be prolonged or repeated. Doctors are also studying the use of other forms of biological therapy for other stages of bladder cancer.

These are some questions patients may want to ask the doctor before starting biological therapy:

• What is the goal of this treatment?
• What drugs will be used?
• What type of treatment schedule will I follow?
• Will the treatment cause side effects? If so, what can I do about them?
• Will I have to be in the hospital to receive treatment?
• How long will I be on treatment?
• Will I be able to continue my normal activities?