I have high-grade bladder cancer. How is it best managed?

Question

Hi doctor,

I am a 68-year-old man with a known history of high-grade muscle-invasive bladder cancer. Over the past month, I have developed increasing lower abdominal discomfort along with a burning sensation during urination.

I am passing blood in my urine almost daily, sometimes with small clots, and I have noticed a marked increase in urinary urgency and frequency. A recent cystoscopy showed a recurrent tumor measuring about 2.5 cm on the posterior wall of the bladder. A CT scan of the abdomen and pelvis revealed mild right-sided hydronephrosis and a few enlarged pelvic lymph nodes.

My recent blood tests showed a hemoglobin level of 10.2 g/dL, creatinine of 1.6 mg/dL, and an elevated LDH of 310 U/L. I have unintentionally lost about 3 kg over the last six weeks and feel persistently fatigued. In the past, I underwent TURBT followed by intravesical BCG therapy, but I had to miss several BCG treatments due to severe bladder irritation.

I am worried that my cancer may have progressed despite treatment.

I would like to know:

Do these findings suggest progression or spread of my bladder cancer, especially to the lymph nodes?
What are the next best steps in management at this stage?
Will I likely need treatments such as chemotherapy, surgery, or both?
Is my kidney function at risk because of the hydronephrosis and rising creatinine?
How can my current urinary symptoms, pain, and fatigue be managed while planning further treatment?

This situation is causing me significant anxiety, and I am looking for clear guidance on prognosis, treatment options, and symptom control moving forward.

Please advise.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I can understand your issues.

Based on the information you have shared, it is essential to recognize that multiple treatment modalities are available in cases like this. Your relative has undergone TURBT (transurethral resection of bladder tumor) and has also received beta-hCG (beta–human chorionic gonadotropin).

At this stage, given the involvement of lymph nodes, the preferred approach is systemic chemotherapy, specifically platinum-based chemotherapy. This treatment plan falls under the category of bladder-preserving strategies.

The goal of this approach is to treat the cancer effectively without removing the urinary bladder, as radical bladder surgery is complex and can have a significant negative impact on long-term quality of life.

In most cases, chemotherapy is given with or without radiotherapy. When radiotherapy is used, it is typically directed to the pelvic region to help control disease in the affected lymph nodes.

If chemotherapy causes significant side effects or leads to deterioration in his general condition, the next step is immunotherapy. Immunotherapy is generally better tolerated and has fewer side effects compared to chemotherapy. It does not cause hair loss, usually does not lead to excessive fatigue, and typically does not impair kidney (renal) function.

Another option is targeted therapy, which works against specific molecular pathways involved in tumor growth. One of its known side effects is peripheral neuropathy (tingling or numbness in the hands and feet). Targeted therapy is usually considered if chemotherapy is not effective, and in some cases, it may be combined with immunotherapy.

Through this stepwise approach, chemotherapy, radiotherapy when indicated, followed by immunotherapy and targeted therapy if needed, we continue to maintain a bladder-preserving treatment strategy, aiming to control the tumor while avoiding bladder removal.

This strategy has shown good effectiveness in appropriately selected patients. Additionally, he may be eligible for clinical trials, which can provide access to advanced treatments and, in many cases, allow him to receive these therapies free of charge.

Regarding his urinary symptoms, these often improve significantly once immunotherapy or targeted therapy begins to work, as tumor burden and inflammation decrease.

I hope this explanation is clear and helpful. Please feel free to reach out if you have any further questions.

Thank you.