What Are Some of the Common Treatment Options for Patients With Advanced Bladder Cancer?
Dr. VanderWeele:
Thinking about more aggressive cancers that are muscle-invasive or that have spread to other places. Right now, the first line of therapy is typically multiple chemotherapy agents given together. Usually, the most important one is one that we call a platinum agent, which can either be cisplatin or carboplatin, and these are drugs that have been around for decades, and typically, other agents are given along with them. And there are various combinations that can be used, but usually, it's two or four different chemotherapy agents that are used at once.
That's often followed up with immune therapy, and there are a number of different immunotherapy options. But they're all related to each other, and generally called checkpoint inhibitors. And again, that's similar for non-muscle invasive bladder cancer. These things are designed to activate your immune system and hopefully, trick the immune system into thinking that the cancer is an infection and to get it to help fight it off. But unlike non-muscle invasive bladder cancer, for bladder cancer that has spread to other places and is metastatic, these things are given by IV, just like the chemotherapy drugs are.
What Is Bladder Preservation Therapy and How Has it Improved in Recent Years?
Dr. VanderWeele:
Often, if there's a patient that has a cancer that's localized to the bladder, so it's still just in the bladder. But it's invading into the muscle, and so we know that it has the potential to spread to other places. Often, a standard treatment is surgery, so a cystectomy. Or, in a man often, we're removing the prostate at the same time, so cystoprostatectomy. But an alternative to that could be a radiation-based approach, so radiotherapy. And really often, we call it a trimodal therapy. So in the right patient, we think that it can be about as effective as removing the bladder. But someone where there's really one dominant tumor, it isn't cancer spread throughout the whole bladder. But one dominant tumor and one that can be removed by the urologist without evidence of much cancer remaining after that.
And so you've gotten rid of the bulk of the cancer surgically, and then you back that up or follow that up with radiation therapy. And that's typically given over many weeks. And then, on top of that, in order to sensitize the cancer cells to radiation, we typically give chemotherapy as well, and that's been shown to improve the effectiveness of the radiation. So it's really the radiation that's more powerful, and the chemotherapy is given at little bit lower doses, but to try to enhance the effectiveness of the radiation.
How Will a Patient and Doctor Know if a Treatment Is Working?
Dr. VanderWeele:
Focusing on advanced cancers or muscle-invasive cancers, typically, it's with monitoring and just making sure that we don't see any sign of the cancer coming back. So it's only looking back and not seeing the cancer show up again. That's when you say, yes, we were successful, and we made this work.
We are now starting to incorporate some other testing. It's still pretty early on. But there are new tests available that fit into this category of looking at minimal residual disease. And really, what mostly these tests are doing are looking for evidence of tumor DNA in the bloodstream as an early marker of cancer still being present. And so, there have been some studies done, where it looks like we can detect tumor DNA in the bloodstream earlier than we can detect tumors showing up, or recurrent cancer on a CT scan, for example. And so that might give us a little earlier advanced warning; that we weren't successful with the curative therapy, whatever it was. Typically, these tests have been done more with surgery, and that there is still an indication that there is cancer left behind.
How Will Treatment Impact Daily Activities?
Dr. VanderWeele:
How great a disruption of life you experience often depends on how fit you are going into it, but it can be difficult to predict. I've also had older patients who tolerated it very well, and other folks who seem to be quite healthy going into it, and it did have a much bigger impact on their quality of life. In general, immune therapy tends to have less of an impact on quality of life. Often, people have relatively mild side effects, although there is a small group of patients that can have much more significant side effects. Often, that can be dealt with fairly well, although people can end up in the hospital having to be hospitalized because of severe side effects, and there could be things that you end up dealing with for months afterward.
Again, that's a relatively smaller group of patients on immunotherapy. If you compare the side effects for people getting immune therapy versus getting chemotherapy, just looking at the numbers and charts reporting these side effects, it's always much more significant for those getting chemotherapy.
