Understanding the range of therapies for bladder cancer in cases where treatment beyond surgery is required.
There’s no one-size-fits all approach to treating bladder cancer. For non-muscle invasive disease, sometimes surgery — along with surveillance to make sure the disease hasn’t returned — is all that is required. But in more aggressive or invasive cases, treatment may also involve medication-based options such as chemotherapy or immunotherapy.
“Treatment options really have been expanding in the past several years,” said Dr. Kristen Scarpato, a urologist with Vanderbilt Urology. “The Food and Drug Administration has given approvals for therapies that target bladder cancer specifically. That’s been really exciting to see — and has opened up additional options for our patients. Also, there are many important clinical trials underway.”
Intravesical therapy
Vanderbilt’s urology team offers intravesical therapy for some cases of early-stage cancer that has not grown into the bladder wall. This treatment involves instilling a medication directly into the bladder. “These medications can be chemotherapy, such as gemcitabine or mitomycin, or may be immunotherapy,” Scarpato said, noting that with chemotherapy, sometimes two medicines can be used at the same time to increase efficacy.
For immunotherapy, one long-standing and effective option is called Bacillus of Calmette Guérin (or BCG). “When placed into the bladder BCG will encourage the immune system to attack cancer cells,” she explained.
Traditional chemotherapy
When cancer has spread into the bladder muscle or beyond, traditional chemotherapy drugs administered through an IV are recommended as part of bladder cancer treatment. “Sometimes we use these therapies in what we call the ‘frontline setting’ — the very first treatment that a patient would get for bladder cancer after the diagnosis,” Scarpato said, “because they are effective therapies that improve cancer outcomes.” Most often, IV chemotherapy for bladder cancer includes a medicine called cisplatin.
Immune-based therapy
Over the last several years, immune-based therapies have been developed to help target various types of tumors. “The goal is to activate the body’s immune system against the cancer,” Scarpato said. “We use immune-based therapy as either the first-line or the second-line treatment option for bladder cancer, depending on the patient’s cancer stage and treatment history and considering the various possible treatment side effects.”
Scarpato said these treatments have demonstrated promising results for patients’ overall prognoses. “Some patients see a long-lasting, durable benefit from these immune-based medicines,” she explained.
Newest therapies
The FDA has granted approval for two novel medications to treat bladder cancer. “One is an antibody drug conjugate,” Scarpato said. “It targets a protein expressed mostly on bladder cancer cells and then it delivers the treatment directly to the bladder cancer cells.” This medication, called Padcev (enfortumab vedotin-ejfv), results in cancer cell death. It can be given alone or used together with another immunotherapy medicine called Keytruda (pembrolizumab).
The other FDA-approved medication is Balversa (erdafitinib), which targets specific genetic changes. Fibroblast growth factor receptors (FGFRs) are cell proteins that help cells grow and divide; some people have gene mutations that encourage cells to make these proteins in a way that promotes cancer cell growth. Balversa is for patients with advanced-stage bladder cancer who have FGFR gene mutation and have tried other treatments. Scarpato said about 10 to 15 percent of patients fall into this category and might be good candidates for this treatment.
Clinical trials for bladder cancer
For eligible patients, clinical trials are another important treatment option for bladder cancer. Scarpato said the team at Vanderbilt tries to have trials available to offer patients across all stages of bladder cancer. “In some cases a clinical trial can be initiated before a patient has had other treatments,” she said. “In other cases, a clinical trial might function as a second- or third-line defense against cancer if other treatments haven’t been effective.”
A personalized approach to treatment
In addition to clinical trial options and medical teams that specialize in urologic cancers, Vanderbilt’s cancer tumor board, made up of multiple experts, meets weekly. “During that time, we review each unique patient and cancer history individually — it is very helpful to get multiple expert opinions all at one time,” Scarpato said. The combined experience and knowledge of the board helps physicians determine the best treatments for their patients who have bladder cancer.
Vanderbilt Health’s Urological Cancers team is dedicated to preventing, diagnosing and treating cancers that affect the kidney, bladder, prostate and testicles. The specialized team works together to provide a precise diagnosis and effective treatment options.
