HJNO Jul/Aug 2022

HEALTHCARE JOURNAL OF NEW ORLEANS I  JUL / AUG 2022 53 Janeiro Goffin, MD Medical Oncologist Terrebonne General | Mary Bird Perkins Cancer Center 1. Non-muscle invasive bladder cancer treatment options include: • Surgery called transurethral resection of bladder tumor (TURBT): TURBT is a procedure in which a physician uses a cystoscope to see inside the bladder and remove any abnormal-appear- ing areas. In certain cases, usually in people with more aggressive cancers, a second TURBTwill be performed sev- eral weeks after the first to ensure no tumor was missed during the original cystoscopy. If all tumor has been re- moved after this second TURBT, the patient will begin adjuvant therapy. • Adjuvant therapy after surgery: Even after TURBT, 50% of people will have a recurrence of their cancer within 12 months. Because of this high recur- rence rate, adjuvant (additional) ther- apy is usually recommended. The type of adjuvant therapy recom- mended depends on the risk of recurrence: Low risk will be advised to have a single dose of chemotherapy inside the bladder. Intermediate risk will be advised to have a full six-week chemotherapy course inside the bladder. The most common chemother- apy used for this is mitomycin, epirubicin, or gemcitabine. Another treatment option is immunotherapy with Bacillus Calmette- Guérin (BCG). Both treatments might need an additional booster for up to one year (maintenance therapy). High risk will be advised to start BCG, usually within two to six weeks of the first treatment. This is most commonly followed by additional booster treatments (mainte- nance therapy) once a complete response is obtained. Some patients are advised to consider bladder removal (cystectomy), es- pecially if the disease is extensive. 2. Muscle invasive bladder cancer treatment options include: • Neoadjuvant chemotherapy: “Neoad- juvant” in this case means chemother- apy that is given prior to surgery. When possible, people with muscle-invasive bladder cancer should consider neoad- juvant chemotherapy before removing the bladder (cystectomy). Examples of neoadjuvant chemotherapy regimens are dose-dense methotrexate, vinblas- tine, doxorubicin, cisplatin (MVAC), or cisplatin/gemcitabine. • Chemotherapy after cystectomy: In some situations, chemotherapy is not given before cystectomy. However, chemotherapy may be recommended for these people after surgery (called adjuvant chemotherapy) if more exten- sive disease is found when the bladder is removed. For example, chemother- apy may be recommended after cys- tectomy in one or both of the follow- ing situations: The tumor extends into the layer of fat surrounding the bladder, or cancerous cells are identified in the lymph nodes that were removed during the cystectomy. An example regimen is cisplatin/gemcitabine. • Immunotherapy: This refers to the use of medicines that work with the pa- tient’s immune system to attack blad- der cancer cells. Adjuvant immuno- therapy is an option for people who have received neoadjuvant chemo- therapy and cystectomy but still have cancer invading the muscle layer of the bladder or involving the lymph nodes after surgery. It is also an option for people who could not (or chose not to) receive neoadjuvant chemotherapy that includes the drug cisplatin before cystectomy but still have cancer ex- tending into the layer of fat surround- ing the bladder or involving the lymph nodes after surgery. Example is pem- brolizumab (Keytruda). • Bladder preservation: In selected peo- ple with invasive bladder cancer, it may be possible to avoid removing the en- tire bladder. This may be an option for frail patients not able to handle surgery. It may also be an option in healthier and younger people who prefer to keep their bladder and have specific crite- ria including T2/T3 disease, hydrone- phrosis, kidney dysfunction, extensive carcinoma in situ, or unifocal tumor <6 cm. The preferred option for blad- der preservation is chemotherapy plus radiation (chemo radiotherapy), which is given after transurethral resection of bladder tumor (TURBT); together, this is often called trimodal therapy. Ex- amples of chemotherapy used for this are five fluorouracil plus mitomycin, cisplatin-based regimen, or single- agent gemcitabine. • Systemic treatment due to metastat- ic cancer or Stage IV disease: Some people will develop metastatic cancer, meaning that the cancer has spread (metastasized) to other parts of the body. Treatment options for patients with metastatic cancer include chemo- therapy, immunotherapy, and targeted therapy. Chemotherapy is usually the first treatment in this situation. If kid- ney function is good, we can use cispla- tin/gemcitabine or carboplatin/gem- citabine if the kidney function is bad. Immunotherapy like pembrolizumab is usually used after chemotherapy or if a person is not eligible for chemother- apy. Drugs that specifically target tu- mor cells, such as enfortumab vedotin, sacituzumab govitecan, or erdafitinib, may also be an option for some people afterward as a third line of therapy. n