Early bladder cancer (e.g. pT1 disease) is treated by the urologist by resection or diathermy, aiming to totally destroy/ surgically excise the entire tumour; this is often possible as the tumour is superficial in the bladder and growing out into the bladder lumen.
After this procedure, and when the pathologist has confirmed that there is no 'deep invasion' of the bladder wall, (which implies that there will be disease left behind and further therapy is needed) the urologist will repeat serial follow-up cystoscopies to be sure there is no recurrence at increasing intervals over many years.
Where there is a superficial ‘carpet’ of tumour across the lining of the bladder some instillations of toxic chemicals (e.g. the chemotherapeutic agents, doxorubicin or mitomycin C) or BCG, (the attenuated tubercle bacillus species) into the bladder may be very useful in clearing the disease by causing a chemical ‘burn’.
For more advanced disease (where there is involvement of the bladder muscular wall) where there is no evidence of spread beyond the bladder, then there are several curative treatment options:
In the younger and fitter patient, then cystectomy (the removal of the bladder with reconstruction of some substitute conduit for the urine) is the standard and often best treatment.
For the older patient who would not stand this large operation, then radical radiotherapy (an external beam course lasting 5-6 weeks) is chosen.
Radiotherapy (or chem-radiotherapy - see below) is also chosen when the disease is through the bladder wall and therefore not potentially curable by cystectomy e.g pT4 disease.
The modern radiation system is with high energy linear accelerators and using conformal technology/ IMRT. The high radiation dose is carefully 'moulded' around the bladder (which is treated empty) as the patient lies on his back on the radiotherapy treatment couch. The treatment takes up to 15 minutes (the majority of this being due to the time taken for the patient to be set-up in the correct position) and the patient feels nothing as the body cannot sense the absorption of this x-radiation. He/she returns the next day (Monday to Friday) for the next treatment ('fraction' in radiotherapy parlance).
Many clinical trials are currently in progress as to the optimal way to treat bladder cancer that is invasive. In general, it has been shown that a course of daily radiotherapy lasting over 5-6 weeks is the optimal way to receive curative radiotherapy and the current controversy is over the concurrent use of chemotherapy.
There is no doubt that modern chemotherapy, using drugs such as cis-platinum and gemcitabine can cause a good regression in transitional carcinoma of the bladder and for younger and fitter patients many would now employ it in conjunction with local therapy (surgery or radiotherapy), but frequently in a clinical trial context.
Sometimes, the use of chemotherapy might come first, with one to three courses of chemotherapy used before the radiotherapy to shrink the tumour and hence maybe make it more radiocurable. Sometimes, chemotherapy is used during radiotherapy in an attempt to get synergy between the two modalities of therapy to enhance the cure chance. There is data to support both points of view but the optimal chemotherapy regime and timing of administration are still subjects of controversy and trial data.