Patients May Want To Think About Taking Part In A Clinical Trial
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today’s standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Treatment Of Bladder Cancer By Stage
Most of the time, treatment of bladder cancer is based on the tumors clinical stage when it’s first diagnosed. This includes how deep it’s thought to have grown into the bladder wall and whether it has spread beyond the bladder. Other factors, such as the size of the tumor, how fast the cancer cells are growing , and a persons overall health and preferences, also affect treatment options.
Where Do These Numbers Come From
The American Cancer Society relies on information from the SEER* database, maintained by the National Cancer Institute , to provide survival statistics for different types of cancer.
The SEER database tracks 5-year relative survival rates for bladder cancer in the United States, based on how far the cancer has spread. The SEER database, however, does not group cancers by AJCC TNM stages . Instead, it groups cancers into localized, regional, and distant stages:
- Localized: There is no sign that the cancer has spread outside of the bladder.
- Regional: The cancer has spread from the bladder to nearby structures or lymph nodes.
- Distant: The cancer has spread to distant parts of the body such as the lungs, liver or bones.
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Treating Stage Iv Bladder Cancer
These cancers have reached the pelvic or abdominal wall , may have spread to nearby lymph nodes , and/or have spread to distant parts of the body . Stage IV cancers are very hard to get rid of completely.
Chemotherapy is usually the first treatment if the cancer has not spread to distant parts of the body . The tumor is then rechecked. If it appears to be gone, chemo with or without radiation or cystectomy are options. If there are still signs of cancer in the bladder, chemo with or without radiation, changing to another kind of chemo, trying an immunotherapy drug, or cystectomy may be recommended.
Chemo is typically the first treatment when bladder cancer has spread to distant parts of the body . After this treatment the cancer is rechecked. If it looks like it’s gone, a boost of radiation to the bladder may be given or cystectomy might be done. If there are still signs of cancer, options might include chemo, radiation, both at the same time, or immunotherapy.
In most cases surgery cant remove all of the cancer, so treatment is usually aimed at slowing the cancers growth and spread to help people live longer and feel better. If surgery is a treatment option, it’s important to understand the goal of the operation whether it’s to try to cure the cancer, to help a person live longer, or to help prevent or relieve symptoms from the cancer.
Because treatment is unlikely to cure these cancers, many experts recommend taking part in a clinical trial.
How To Optimally Manage Elderly Bladder Cancer Patients
Francesco Soria1,2, Marco Moschini1,3, Stephan Korn1, Shahrokh F. Shariat1,4,5
1Department of Urology, Medical University of Vienna, Vienna, Austria 2Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, 10126 Turin, Italy 3Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy 4Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA 5Department of Urology, Weill Cornell Medical College, New York, USA
Contributions: Conception and design: F Soria, SF Shariat Administrative support: None Provision of study materials or patients: All authors Collection and assembly of data: All authors Data analysis and interpretation: F Soria, SF Shariat Manuscript writing: All authors Final approval of manuscript: All authors.
Correspondence to:
Keywords: Bladder cancer old elderly geriatric patients radical cystectomy chemotherapy
Submitted Mar 04, 2016. Accepted for publication Mar 22, 2016.
doi: 10.21037/tau.2016.04.08
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There Are Three Ways That Cancer Spreads In The Body
Cancer can spread through tissue, the lymph system, and the blood:
- Tissue. The cancer spreads from where it began by growing into nearby areas.
- Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
- Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.
After Bladder Cancer Has Been Diagnosed Tests Are Done To Find Out If Cancer Cells Have Spread Within The Bladder Or To Other Parts Of The Body
The process used to find out if cancer has spread within thebladder lining and muscle or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:
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Chemotherapy: Neoadjuvant And Adjuvant
Cisplatin-based neoadjuvant chemotherapy improves overall survival for patients with MIBC by approximately 5% at 5 years compared with RC alone.28 Furthermore, NAC doubles the rate of pathologic CR at the time of RC from 10%â15% to 30% for patients who experience pathologic CR, the 5-year overall survival is improved to 85%.29 Trials of cisplatin-based adjuvant chemotherapy, including a recently published study, have been underpowered to detect a statistically significant improvement in outcomes compared with those having RC alone largely due to a failure to accrue.30 Thus, based on the proven benefit and level of evidence, NAC is the preferred approach to management for patients with MIBC who are eligible to receive cisplatin-based chemotherapy.31
Despite the endorsement of national guidelines, the use of cisplatin-based NAC is limited in contemporary clinical practice, both in the community and at academic centers.32 Factors that impact the use of NAC are complex and include misperceptions on the part of both physicians and patients regarding a lack of benefit and increased toxicity. A coordinated multidisciplinary approach to management has been shown to increase use of NAC and is proposed as a quality indicator of care for MIBC.33,34 The incorporation of a geriatric oncologist or geriatrician skilled in the administration and interpretation of the comprehensive GA may help to prospectively identify patients at increased risk for chemotherapy-induced toxicity.35
Experiences Of Living With Cancer
The research originated, in part, from Kesslers previous studies that have been supported by an American Cancer Society clinician scientist award. In one study, she and her co-researchers analyzed data from the National Cancer Institutes Surveillance, Epidemiology, and End Results Program, finding that the majority of older adults with advanced bladder cancer dont receive anti-cancer treatment.
If thats happening, if we look at just the claims data and see thats happening, there has to be so much more to the why, Kessler explains. Is it because of ageism? Because patients dont want treatment? We wanted to learn more about what patient priorities are as were thinking through how that initial treatment planning is set up for patients.
Kessler and her co-researchers interviewed ten older advance bladder cancer patients through focus groups and individually. Many of those surveyed had previously received a diagnosis of localized bladder cancer that had either recurred or progressed.
We found that these patients continued to take themselves back to the initial cancer diagnosis, Kessler says. They could remember the wording, they could remember the first time they were diagnosed with cancer. Even though it was initially localized and curable, I thought it was going to be such a shift when they heard they have this more advanced state. But for many it wasnt, it seemed to be more of a signpost along the way.
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What Increases Your Chances Of Getting Bladder Cancer
Anything that increases your chances of getting a disease is called a risk factor. The main risk factors for bladder cancer include:
- Smoking. Cigarette smokers are much more likely than other people to get bladder cancer.
- Being older than 40, being male, or being white .
- Being exposed to cancer-causing chemicals, such as those used in the wood, rubber, and textile industries.
- What you eat. A diet high in fried meats and fats increases your risk for bladder cancer.
- Parasites. There is a parasite that causes schistosomiasis, which can increase your risk. This condition is sometimes found in developing countries and rarely occurs in North America.
Optimizing Radical Cystectomy Outcomes In Elderly Patients
As previously mentioned, the morbidity associated with RC is high and potentially worse for elderly patients. A prolonged postoperative ileus is the most common complication following RC . Although, there is no standardized definition for PPOI and the pathophysiology contributing to this process is rather complex, several attempts have been made at decreasing the incidence of PPOI, ranging from pharmacologic agents to gum chewing . PPOI has previously been shown to be a common cause of a prolonged length of hospital stay following RC. When we evaluated our RC experience of 330 consecutive patients for perioperative risk factors associated with a prolonged LOS 12 days, only older age and female gender were statistical significant on multivariate analysis . Those with a prolonged LOS had significantly similar cancer specific outcomes but worse overall survival .
Another important consideration in the elderly is the rate of delirium following RC. It has recently been shown to be 29 % following RC in patients older than 65 years . Delirium is associated with an increased risk of morbidity and mortality after many surgical procedures . Unfortunately, it is often under detected by health care providers. Evidence suggests that the involvement of geriatricians with in-patient care after surgery may decrease the risk of postoperative delirium .
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Patients Can Enter Clinical Trials Before During Or After Starting Their Cancer Treatment
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. Information about clinical trials supported by NCI can be found on NCIs clinical trials search webpage. Clinical trials supported by other organizations can be found on the ClinicalTrials.gov website.
Bladder Cancer Clinical Trials
What about Clinical Trials?
You may hear about clinical trials for your bladder cancer. Clinical trials are research studies that test if a new treatment or procedure is safe and effective.
Through clinical trials, doctors find new ways to improve treatments and the quality of life for people with disease. Trials are available for all stages of cancer. The results of a clinical trial can make a major difference to patients and their families. Please visit our clinical trials research webpage to learn more.
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Bladder Cancer Stages And Survival Rates
Cancer survival rates are also categorized according to the stage of the cancer when it was diagnosed. The stage of cancer generally refers to how far it has progressed, and whether it has spread to other parts of the body. For bladder cancer, the 5-year survival rate for people with:2,3
- Bladder cancer in situ is around 96 percent
- Localized bladder cancer is around 70 percent
- Bladder cancer that has spread to the regional lymph nodes is 35 percent
- Distant or metastasized bladder cancer is 5 percent
If you would like to learn more about bladder cancer statistics, consider speaking with someone on your health care team. They will be able to explain more about how these statistics apply to your cancer. Tell us about your experience in the comments below, or with the community.
The Following Stages Are Used For Bladder Cancer:
Stage 0
In stage 0, abnormalcells are found in tissue lining the inside of the bladder. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is divided into stages 0a and 0is, depending on the type of the tumor:
- Stage 0a is also called noninvasive papillary carcinoma, which may look like long, thin growths growing from the lining of the bladder.
- Stage 0is is also called carcinoma in situ, which is a flat tumor on the tissue lining the inside of the bladder.
Stage I
In stage I, cancer has formed and spread to the layer of connective tissue next to the inner lining of the bladder.
Stage II
In stage II, cancer has spread to the layers of muscle tissue of the bladder.
Stage III
Stage III is divided into stages IIIA and IIIB.
- In stage IIIA:
- cancer has spread from the bladder to the layer of fat surrounding the bladder and may have spread to the reproductive organs and cancer has not spread to lymph nodes or
- cancer has spread from the bladder to one lymph node in the pelvis that is not near the common iliac arteries .
Stage IV
Stage IV is divided into stages IVA and IVB.
- In stage IVA:
- cancer has spread from the bladder to the wall of the abdomen or pelvis or
- cancer has spread to lymph nodes that are above the common iliac arteries .
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Muscle Invasive Bladder Cancer
MIBC is an aggressive tumor with a poor prognosis the 5- and 10-year overall survival rates are around 65% and 45% respectively, closely related to the disease stage . MIBC may arise de novo or as the result of a progression of NMIBC. If untreated it will lead to local invasion of adjacent structures, hydronephrosis, incoercible hematuria, lymph node and distant metastases . Nowadays the only treatment with a curative intent is RC, eventually preceded by neoadjuvant CHT when possible. Despite these evidences, many older patients do not receive curative treatments. Analyzing the report of the SEER, Gore et al. found that only 21% of MIBC patients older than 65 years received a RC . The predictors for this were urologist choice, longer travel distances and residence in rural areas. These observations have been confirmed analyzing data from the USA National Cancer Database. Cystectomy rate was 55% in patients younger than 70 years, 45% in those 70 to 79 years, and it decreased to 21% in those older than 79 years. Half of patients older than 85 years received no treatment . Reasons for denying old patients major surgery are multi-factorial, but they are mainly based on the perception that many patients will not tolerate RC and urinary diversion because of age and comorbidities. For this reason, an integrate and multidisciplinary approach to this category of patients is mandatory. The evaluation has to be run by the urologist, oncologist, radiotherapist and geriatricians.
Involving Patients In Care Discussions
Among the themes that emerged from interviewing the study participants was a consistent desire for early, honest, and transparent communication from caregivers. They expressed a desire for information about what to expect with changes to their physical abilities, mobility, and independence.
We learned that they really do want to be involved in discussions of their care and to have clear expectations for their treatment, Kessler says. They want to be engaged early in the process and not feel like theyre waiting or wishing for information.
Also, while there was some variation among study participants about how they wanted their care partners, who often were spouses or family members, involved in discussions of their care, they expressed a desire for a clear understanding of what the care partners role would be.
Researchers further found that study participants didnt feel that discussions of their prognosis and treatment had to happen only with medical doctors, but could happen with nurses, physician assistants, or other informed members of their care team.
What weve found is that patients really do want to talk about their prognosis and treatment right from the beginning, Kessler says. Instead of focusing on alignment at end-of-life, now were looking at ways to come up with a treatment plan that better aligns care for people right from the start.
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Treating Bladder Cancer That Progresses Or Recurs
If cancer continues to grow during treatment or comes back after treatment , treatment options will depend on where and how much the cancer has spread, what treatments have already been used, and the patient’s overall health and desire for more treatment. Its important to understand the goal of any further treatment if its to try to cure the cancer, to slow its growth, or to help relieve symptoms as well as the likely benefits and risks.
For instance, non-invasive bladder cancer often comes back in the bladder. The new cancer may be found either in the same place as the original cancer or in other parts of the bladder. These tumors are often treated the same way as the first tumor. But if the cancer keeps coming back, a cystectomy may be needed. For some non-invasive tumors that keep growing even with BCG treatment, and where a cystectomy is not an option, immunotherapy with pembrolizumab might be recommended.
Cancers that recur in distant parts of the body can be harder to remove with surgery, so other treatments, such as chemotherapy, immunotherapy, targeted therapy, or radiation therapy, might be needed. For more on dealing with a recurrence, see Understanding Recurrence.