By Michael A. O’Donnell‚ MD
Associate Professor and Director of Urologic Oncology
University of Iowa College of Medicine

Q: What’s new in the treatment of bladder cancer? I have just been diagnosed with early bladder cancer and want to know my options.

A: If you are like most people recently diagnosed with bladder cancer‚ you probably have “superficial” disease in the inner half of the bladder surface. This relative shallowness allows your surgeon–urologist to literally scrape out your tumor from the inside using a special lighted telescopic device called a cystoscope. This procedure is generally referred to as a TURBT (Trans Urethral Resection of Bladder Tumor) and is quite effective in both eliminating the tumor and establishing the grade (a measure of aggressiveness: low‚ intermediate‚ and high) as well as the stage (a measure of relative depth).

A new technology being developed in Europe helps urologists see more of the tumor by putting special dyes in the bladder that cause tumors to glow under ultraviolet light. Using this advanced technology‚ urologists can visualize an average of 15% more tumors. This reduces the recurrence rate for bladder cancer by 10–15% over conventional “white” light TURBT.

Further benefit can be achieved with the routine use of one–dose chemotherapy administered immediately into the bladder after the TURBT. It will not seep into the rest of your body when administered in this manner.

Standard chemotherapy drugs such as Mutamycin® (mitomycin)‚ Adriamycin® (doxorubicin)‚ and Thioplex® (thiotepa) have all been shown to be effective and reduce the chance of tumor recurrence from the usual 60% to about 45%. Scientific research suggests these drugs work by preventing tumor cell reimplantation‚ a sort of “dandelion” effect that occurs when tumor cells break off during routine TURBT.

Aggressive cancer requires additional topical therapy. Traditionally this had been intravesical (placed into the bladder) chemotherapy of the type mentioned above‚ applied once weekly for six weeks.

Results may be improved by relatively simple maneuvers such as overnight fasting‚ taking bicarbonate to neutralize urine acidity‚ emptying the bladder completely beforehand‚ and using a more concentrated form of the drug.

Combining these techniques doubles the effectiveness of Mutamycin®. Combining intravesical chemotherapy with microwave hyperthermia is yet another option that has yielded superior results in European clinical trials (currently up for U.S. Food and Drug Administration approval in the United States).

The most effective intravesical agent is the live tuberculosis (TB) vaccine BCG (Bacteria of Calmett–Guérin). BCG is also applied once weekly for six weeks beginning about three weeks following TURBT. It should NEVER be applied immediately after TURBT because it can cause a severe TB–like illness if it gets into the bloodstream through an open wound.

However‚ given appropriately‚ it is generally safe and incites a strong immune response in the bladder‚ resulting in shedding of the inner lining along with the cancer.Several new advances in BCG therapy have come about to improve its effectiveness. One is the use of further “booster” cycles given as three–week mini–series three to six months after the original six–week cycle.

Another improvement includes the incorporation of the immune–stimulating agent interferon that has been shown to increase the potency of BCG. High–dose antioxidant vitamin supplements‚ especially A‚ C‚ D‚ and E may further prevent recurrence after BCG therapy.

Unfortunately‚ even under the best of care‚ 25% of superficial bladder cancers progress to the life–threatening stage. In patients who progress or present with more bladder cancer‚ treatment often involves a combination of surgery‚ chemotherapy‚ and radiation therapy.

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