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If you or a loved one has been diagnosed with muscle-invasive bladder cancer (MIBC), you may be looking for more information about treatment options and wondering what course of treatment will be right for you. When making decisions about the next steps in your cancer treatment, your healthcare team will first determine the stage and grade of your bladder cancer and discuss your treatment preferences with you. This means they will take a closer look at how severe your cancer is, how much it has spread, and how much risk there is of it coming back.
With muscle-invasive bladder cancer, cancer cells grow beyond the inner lining of the bladder, going into or through the muscle layer of the bladder. Around 25 percent to 30 percent of bladder cancer tumors become muscle-invasive. When this happens, advanced bladder cancer has a higher risk of spreading outside the bladder wall to other parts of the body.
Without treatment, MIBC can be life-threatening. It’s important to take an MIBC diagnosis seriously. Bladder cancer is treated by a urologist (a urinary tract specialist) and an oncologist (a cancer specialist), who will work together to recommend the best treatment options for you.
Surgery is usually the first treatment when you’re diagnosed with any kind of bladder cancer. There are a few different kinds of surgery your doctor may recommend, depending on your diagnosis, age, and quality of life.
Transurethral resection of bladder tumor (TURBT) is usually the first step and is minimally invasive. TURBT is performed using a medical device that enters your bladder through your urethra. This device has a scope that your doctor can use to inspect your bladder, as well as a cutting tool that your healthcare team can use both to take tissue samples of the cancer they find and to remove as much tumor tissue as possible from inside your bladder. If you have MIBC, the doctor will usually not be able to remove all of your cancer during this surgery, but they can start. The main goal of this procedure, when you have MIBC, is to inspect and take samples that will help your healthcare team determine how much your cancer has metastasized (spread), where it has spread to, and what kind of cells it is made of.
However, in some cases, TURBT can be followed by chemotherapy given at the same time as radiation to avoid more invasive surgery and help preserve bladder function. This is called trimodality therapy. Your follow-up appointments and procedures will continue treatment based on what your doctors find.
If you have MIBC, your doctor may recommend removing part or all of your bladder either before or after other treatments. This surgery is called a cystectomy. You have a choice of whether to do this surgery.
Most often, a radical cystectomy will be performed to remove your entire bladder, surrounding lymph nodes, and parts of any nearby organs where the cancer has spread. Depending on your anatomy, your doctor may remove some of the following during your radical cystectomy:
Bladder cancer surgery to remove your bladder can be done via open surgery (where the doctor makes one incision across your abdomen) or by laparoscopic surgery (where the doctor makes a few small incisions, sometimes called keyhole incisions, and uses thin, telescoping tools to do the procedure without making a long incision).
Recovery from a cystectomy usually includes staying in the hospital for five to 10 days. You will usually start walking the day after the operation. You may be on a liquid diet for a few days and a modified diet for a bit longer, which usually includes drinking a lot of water and eating foods that are easy to digest.
Some people with MIBC who have tumors only in one part of the bladder may be able to have a partial cystectomy, where only part of the bladder is removed. Having a partial cystectomy means that reconstructive surgery isn’t needed because the bladder stays in the body.
However, this type of surgery isn’t used often for MIBC, because muscle-invasive bladder cancer has usually spread to more than one spot in the bladder. Since it’s really important to remove all of the cancer, doctors will not recommend this option if there’s a risk that cancer could still be in other parts of your bladder. When recommended, it has to be performed after systemic treatments like chemotherapy and immunotherapy.
Of course, removing your bladder is a big deal, but you don’t need a bladder to survive. If you have a complete bladder removal (radical cystectomy), your doctors will need to create a different way for urine to leave your body. Your care team will help make sure you understand the options and feel comfortable with the next steps.
Often, they use reconstructive surgery to create a replacement bladder from a piece of your intestine. Sometimes, a replacement bladder can be connected to your urethra, enabling you to pee normally. Other times, it’s necessary to create an opening in your skin so that your urine can exit the body through a tube or into a bag. Using a tube or bag to urinate might seem scary or uncomfortable, but many people regain a high quality of life and can still live a fulfilling life and do activities that they enjoy, even without a bladder.
Treatment for MIBC will almost always include one or both of the surgeries mentioned above (TURBT and cystectomy) and can sometimes also include chemotherapy. Chemotherapy for MIBC uses anticancer drugs that circulate through your whole body in your bloodstream. The chemotherapy drugs attack cancer cells to kill them or stop them from multiplying.
Intravesical chemotherapy is another type of bladder cancer chemotherapy where chemotherapy drugs are put directly into the bladder. This treatment isn’t used very often for MIBC, since it’s not as effective for cancer that has spread beyond the bladder wall or lining.
In MIBC, chemotherapy is often given before bladder removal surgery to make it easier to remove the cancer and lower the risk of it coming back (also called recurrence). When you get chemo before surgery, that’s called neoadjuvant therapy. Before bladder surgery, the usual chemotherapy is a cisplatin-based combination, most often gemcitabine and cisplatin or dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin. These combinations work better than single drugs.
Your doctor may also recommend chemotherapy after surgery to kill any cancer cells that could have been left behind and to reduce the chances of cancer coming back. This is called adjuvant therapy. When given both before and after surgery, it is known as perioperative chemotherapy.
Sometimes, if bladder-removal surgery is not recommended or you don’t want to have the procedure, doctors will recommend a bladder preservation or bladder-sparing approach that uses chemotherapy in combination with radiation. A bladder-sparing plan that combines TURBT, chemotherapy, and radiation can be an option in carefully chosen situations. In these cases, cancer control can be similar to bladder removal, but it needs close follow-up.
Because chemo drugs are strong, they can kill fast-growing cancer cells but also sometimes harm other cells, which causes side effects. Side effects of chemotherapy can include nausea, vomiting, loss of appetite, hair loss, and increased risk of infection.
Immunotherapy is a cancer treatment that helps your immune system recognize and fight cancer cells. As a treatment for MIBC, immunotherapy is a new and rapidly developing treatment option, thanks to the latest in cancer research. Today, immunotherapy is mainly used around the time of surgery or for advanced disease. It isn’t usually used by itself to save the bladder.
Immunotherapy is often used after bladder removal (adjuvant treatment) or as part of a planned perioperative regimen. It’s not usually paired with TURBT. Key options today include adjuvant nivolumab (a PD-1 blocker) after surgery for higher-risk disease, enfortumab vedotin and pembrolizumab used before and after surgery for people who can’t get cisplatin, as well as durvalumab in combination with chemotherapy before surgery and alone after surgery.
Immune checkpoint inhibitors are drugs that help the functioning of the immune system (they block the PD-1/PD-L1 pathway). In MIBC, they’re used after surgery (for higher-risk cases) and, for people who can’t get cisplatin, as part of a plan before and after surgery with enfortumab vedotin and pembrolizumab.
Clinical trials are needed to help fully realize the potential of immunotherapy as a bladder preservation therapy for MIBC that both preserves quality of life and assures the same likelihood of becoming cancer-free as a bladder-removal surgery. Cancer research makes progress every day. There is more to be optimistic about than ever in terms of treatment options and health outcomes for people with muscle-invasive bladder cancer. No matter what you’re facing, it’s important to remember that you’re not alone.
On MyBladderCancerTeam, people share their experiences with bladder cancer, get advice, and find support from others who understand.
What treatment options are you considering for MIBC? Let others know in the comments below.
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