If one interprets the findings from the Grossman study (neoadjuvant chemotherapy for invasive bladder cancer) from 2003 NEJM, all patients with muscle invasive bladder cancer, eligible for cisplatin should be offered neoadjuvant therapy. This is a simplified answer for another complex question. Obviously age, comorbid factors come to play including renal function.

The best way to manage urinary control problems due to prostate cancer is to have your operation or radiation administered in the best possible way to try to prevent the problem from occurring in the first place.

If urinary control is a problem after radiation treatment, options are few, because incontinence results from radiation damage to the bladder itself. If urinary control is a problem after operation, it can represent an abnormal bladder that existed prior to operation as the result of an enlarged prostate, which may allow the urinary control problem to improve over a period of several years (while the bladder adjusts to no longer voiding past an enlarged prostate). If the problem is due to damage to the urinary sphincter mechanisms, the external sphincter can often be strengthened through Kegel exercises. Properly performed Kegel exercises are the cornerstone to management of men with poor urinary control after prostatectomy. Failing this, there are other treatments that involve an operation, such as a urethral suspension or an artificial urinary sphincter placement.

Assuming the bladder has not been removed, surgery is the primary treatment if a patient does not respond well to chemotherapy prior to surgery. In cases where patients have already had their bladders removed and have disease throughout other parts of the body, second line chemotherapy can be considered. There are some experimental trials for patients in this situation.

Must be a cisplatin based regimen, classic mvac, dose dense mvac and gc are acceptable alternatives including split dose cisplatin dosing. Carboplatin is not an acceptable alternative, although in certain situations, it may be used in a palliative (noncurative manner).

The standard reasons for bladder removal for bladder cancer include: invasive bladder cancer that penetrates the bladder wall/muscle; bladder cancer that has yet to invade the muscle but has properties associated with a risk of invasion and does not respond to other less aggressive treatments; and recurrent bladder cancer that can not be adequately managed with techniques of removal through the urethra. Due to the lethality of invasive bladder cancer, bladder removal is virtually part of every treatment algorithm designed to cure invasive bladder cancer.

There are several types of bladder cancer, but more than 90% and the one we mean when we say bladder cancer is a cancer of the lining of the urinary tract, previously termed transitional cells, and now termed urothelial cells. Transitional cell or urothelial cell carcinoma of the bladder is primarily described in two ways, by grade and by stage.

Grade is the microscopic appearance of the cancer cells. Very abnormal appearing cells are termed “high grade” and more normal cells are termed “low grade.” Tumor stage is the location or extent of the tumor. Ta is cancer in the lining only, T1 extends into the supportive layer just below the lining (lamina propria), and T2 and higher extends into the muscle or beyond. Both grade and stage are used to predict the risk of bladder cancer. For tumors that do not invade muscle (below T2), high grade disease is the best predictor of dying from bladder cancer. Lamina propria invasive tumors (T1) regardless of grade have increased risk of progression. Another high grade bladder cancer is termed “carcinoma in situ” (CIS; cancer in place). CIS is very early, but very dangerous cancer.

Treatment of bladder cancer is now guided by risk categories that are primarily determined by tumor grade and stage. BCG was first approved for CIS, and subsequently became recommended for all high risk patients. High risk patients are all those with high grade disease, T1 disease, or CIS. BCG or intravesical chemotherapy was recommended for intermediate risk disease, but in 2011 a 942 patient randomized European trial compared BCG and epirubicin chemotherapy found that intermediate risk patients treated with BCG had significantly lower risk of tumor recurrence, metastasis and death. Therefore, strong evidence now reveals that BCG is indicated in intermediate risk patients.

Low risk patients are those with a single, low grade, Ta tumor. These patients are at very low risk for progression, and resection plus a single postoperative instillation of chemotherapy is recommended. Intermediate risk patients are those who are between high and low risk definitions. Chemotherapy or BCG can be given to these patients, but if their tumor recurs after chemotherapy BCG is recommended.

No drug is currently available for prevention of primary bladder cancer, although many agents are under clinical and preclinical evaluation. Approximately 80% bladder cancers are superficial at initial presentation (no invasion into the muscle), most of which will recur after surgical removal of the cancer. Current chemopreventive strategies are aimed at inhibiting the recurrence of superficial bladder cancer. BCG, mentioned before, which is an attenuated bacterium, is most commonly used in the clinic, but in patients BCG fails or is contraindicated, chemical agents (e.g. mitomycin) are used. All agents are delivered intravesically via a urethral catheter, which is intended to avoid or reduce systemic side effects of the drug. My lab has been working to develop oral agents that can be selectively delivered to bladder via urinary excretion, doing away with urethral catheter. Promising results have been obtained, but still in the preclinical stage. If anyone is interested in these studies, please read Bhattacharya et al., Inhibition of bladder cancer development by allylisothiocyanate, Carcinogenesis, 31, 281-286, 2010 or Bhattacharya et al., Allylisothiocyanate-rich mustard seed powder inhibits bladder cancer growth and muscle invasion, Carcinogenesis, 31, 2105-2110; 2010.

Routine blood tests for blood counts since chemotherapy routines cause cytopenias. Liver kidney tests electrolytes are all routine since they can be affected directly or indirectly by the use of chemotherapy. There is no reliable tumor marker although cea is occasionally used for those instances of neuroendocrine differentiation, use of chromogranin A and neuron specific enolase may be helpful as well. Staging imaging typically ct or mri, occasionally pet scanning maybe used every 2-3 cycles to monitor response to therapy.

The first line chemotherapy (drug therapy through the veins) most often involves a regimen of more than one drug including an agent called cisplatin. The “old fashioned” standard was to use 4 drugs: methotrexate, vinblastine, adramycin and cisplatin. More recently, many chemotherapy regimens have consisted of two drugs: gemcitibine and cisplatin. Depending of the preference of your oncologist, one of those two regimens is employed. In some cases, carboplatin is substituted for cisplatin due to problems in kidney function in patients but this is felt to be less effective. Most first line therapy last approximately 3 to 4 weeks.

Obviously the extent of disease at presentation, stage 4, despite its advanced nature may be widely metastatic where systemic therapy is priority whereas bulky primary may benefit from radiation with sensitizing chemotherapy upfront. Or if local complications of urinary or bowel obstruction are present then local surgical or radiation techniques prior to systemic therapy. This is obviously a complex question best addressed in a multidisciplinary manner such as a tumor board discussion preferably with genitourinary specialists such as our semiweekly GU tumor board we have at UCLA Institute of Urologic Oncology.