Trimodal Therapy for Invasive Bladder Cancer

What Is Trimodal Therapy?

As the name suggests, trimodal therapy combines three surgical procedures: radiation therapy, chemotherapy, and transurethral resection of the bladder or partial cystectomy. This therapy is beneficial for people who do not want to lose their bladders, cannot undergo surgery, and the bladder is working fine but there is a small tumor. Trimodal therapy mainly involves a short surgery to remove the tumor, chemotherapy to slow down the growth of cancer cells, and radiotherapy to kill the remaining cancer cells. Studies have reported that six percent of people diagnosed with muscle-invasive bladder cancer did not require radiotherapy as their condition improved after surgery and chemotherapy. Trimodal therapy has provided good oncologic outcomes and low morbidity than radical cystectomy.

What Is a Urinary Bladder?

The urinary bladder is one of the most crucial organs of the urinary system. It is a balloon-like structure connected to the kidneys on one end and the urethra on the other. The ureters are tube-like structures that connect the urinary bladder to the kidneys. The urinary bladder receives urine from the ureters. It sends signals to the brain that the bladder is full and the person needs to urinate. The urethra serves as a connection between the bladder and the outside world. The urine exits the body through the urethra. The junction where the urinary bladder meets the urethra is the bladder neck. It consists of muscles that contract and relax to facilitate urine drainage.

What Is Muscle-Invasive Bladder Cancer?

The human body comprises billions of cells that undergo rapid growth and proliferation. Cancer occurs when these cells show uncontrolled growth. When cancer originates from the bladder, it is known as bladder cancer. It is mainly confined to the tissues lining the inner wall of the bladder. However, the problem arises when cancer spreads to the bladder muscles. The urinary bladder contains a detrusor muscle that contracts and relaxes to push the urine down the bladder to the urethra. When cancer spreads from the detrusor muscle to the surrounding organs, it is known as muscle-invasive bladder cancer. Studies have reported that about 25% of bladder cancers invade the muscles. Therefore, trimodal therapy is the treatment of choice in muscle-invasive bladder cancer.

How Does Bladder Cancer Develop?

The bladder wall contains several layers and is made of different cells. Most bladder cancers start from the inner lining of the wall, mainly the transitional epithelium or urothelium. Transitional cell carcinoma or urothelial carcinoma is the most common type of bladder cancer. The problem arises when cancer spreads out of the layers of the bladder wall. For example, it might invade the surrounding organs and the abdominal lymph nodes. Once cancer invades the bladder wall, there is a chance that it might damage the bones, lungs, liver, and other body parts. Sometimes, cancer might have damaged the other organs, but the bladder works fine. The doctor usually recommends trimodal therapy to save the urinary bladder in such a situation.

What Are the Signs and Symptoms of Bladder Cancer?

The symptoms of bladder cancer are similar to many other urologic conditions, so it is difficult for the patient to recognize cancer. However, the following symptoms are usually seen in bladder cancer:

• Hematuria or blood in the urine.

• Dysuria (painful urination).

• Urinary frequency (urinating more than eight times a day).

• Urinary urgency (a strong urge to pass urine frequently).

• Pain in the lower back and abdomen.

What Are the Causes and Risk Factors for Bladder Cancer?

Bladder cancer occurs due to the changes in the bladder cells' deoxyribonucleic acid (DNA). The DNA present in the bladder cells contains information about the working of the bladder. Mutations or genetic defects command the cells to multiply rapidly. As a result, the healthy cells die, resulting in the formation of a tumor. This tumor turns malignant (cancerous), invades the other body organs, and damages them. The risk factors for bladder cancer are listed below:

• Smoking: When a person smokes, harmful chemicals accumulate in the body. Some chemicals accumulate in the urinary bladder and irritate the bladder lining. As a result, the risk of bladder cancer increases.

• Aging: The risk of bladder cancer increases with age. Most people diagnosed with bladder cancer are usually 55 years old or above.

• Chemical Exposure: People working in the textile, rubber, and leather industries are more likely to develop bladder cancer. The harmful chemicals released by these industries accumulate in the bladder and the kidneys.

• Previous Cancer Treatment: Anti-cancer drugs like Cyclophosphamide increase bladder cancer risk. People who receive radiotherapy for pelvic cancer are more likely to develop bladder cancer.

• Bladder Inflammation: People suffering from chronic bladder inflammation (cystitis), urinary tract infections, and prolonged catheter use are more likely to develop bladder cancer.

How Is Bladder Cancer Diagnosed?

Bladder cancer does not become visible on physical examination. Instead, laboratory tests and imaging tests must be done to confirm the diagnosis. The diagnostic methods have been described below:

• Medical History: The medical history provides an idea about the general health of the patient, the symptoms of the condition, the time of their onset, and the family history.

• Laboratory Tests: The following laboratory tests are usually recommended to know about the general health of the patient:

  • Blood Test: The doctor recommends the patient undergo a blood test to know about the body's general health and if any other infection is present in the body.

  • Urine Test: The patient collects urine in a container or a sterile bag provided by the hospital. It detects blood, bacteria, white blood cells, and stones in the urine.

• Imaging Tests: The following imaging tests are usually recommended to confirm the diagnosis:

  • Magnetic Resonance Imaging (MRI) Technique: As the name suggests, this technique uses magnetic fields and radio waves to produce images of the organs. It is one of the most effective imaging methods used to diagnose bladder cancer.

  • Cystoscopy: It is a procedure in which the surgeon inserts a cystoscope in the bladder through the urethra to examine the bladder lining. Cystoscopy helps to look for the signs of bladder diseases.

• Biopsy:The doctor inserts a needle into the bladder to obtain a tissue sample. Next, the sample is examined under a microscope to detect the cancer cells in the laboratory.

How Is Trimodal Therapy Used for the Treatment of Invasive Bladder Cancer?

Bladder cancer is a serious condition and requires emergency medical care and attention. The three steps of trimodal therapy are listed below:

• Transurethral Resection of the Bladder Tumor (TURBT): It is a diagnostic and therapeutic tool used against invasive and non-invasive bladder cancers. The doctor inserts a cystoscope into the bladder through the urethra during this procedure. It is a telescope-like instrument that helps to locate the bladder lining. Next, the doctor passes an electric wire loop through the cystoscope into the bladder. This wire loop generates an electric current to burn the cancer cells. Instead of the wire loop, a high-energy laser can also be used. As transurethral resection is a minimally-invasive procedure, the doctor will not make any incisions in the abdomen. As a result, the healing is rapid, and the patient experiences minimal surgical trauma.

• Chemotherapy: Chemotherapy is the second step of trimodal therapy. It is a procedure in which high-dose drugs are administered to the patient to kill the cancer cells or slow down their growth. Methotrexate, Vinblastine, Cisplatin, and Doxorubicin are the most commonly used chemotherapeutic drugs against bladder cancer. The methods used to administer the drugs are listed below:

• Intravenous Method - In this method, the drugs are injected into the patient’s vein before or after the surgery.

• Intravesical Therapy - It is a procedure wherein the drugs are injected into the bladder by passing a tube through the urethra.

• Radiation Therapy - It is the final step of trimodal therapy. As the name suggests, radiation therapy uses high-energy beams such as X-rays and photons to destroy cancer cells. A machine moves around the patient’s body to deliver the radiation that helps treat bladder cancer. Sometimes, radiation therapy is used along with chemotherapy when the patient is unwilling to undergo surgery.

Conclusion:

Trimodal therapy has gained a lot of popularity over the past few years. It is an effective method to treat bladder cancer in patients reluctant to undergo surgery. It is a conservative treatment method because the bladder remains intact, and only the tumor cells are removed. Unfortunately, most people are unaware of this therapy and become depressed when diagnosed with cancer. They feel that cancer is the end of life and refrain from undergoing any treatments because of the fear of surgical trauma. Trimodal therapy is a boon for such patients because it targets the cancer cells without damaging the bladder. Also, the chances of cancer recurrence are negligible because chemotherapy and radiotherapy kill the remaining cancer cells. So, the patient must not lose hope and consult the doctor immediately to learn more about trimodal therapy.