What is Muscle Invasive Bladder Cancer (MIBC)?
Muscle invasive bladder cancer (MIBC) is a cancer that spreads into the detrusor muscle of the bladder. The detrusor muscle is the thick muscle deep in the bladder wall. This cancer is more likely to spread to other parts of the body. About 1 out of 4 people who get bladder cancer in the United States have the muscle invasive kind.
Bladder cancer is the 6th most common cancer in the United States. Over 81,000 people will be diagnosed in the United States with bladder cancer this year. This includes nearly 62,000 men and 19,000 women. About 25% of bladder cancers are MIBC.
Bladder cancer is more common as a person grows older. It is found most often in the age group of 75-84. Caucasians are more likely to get bladder cancer than any other ethnicity. But, there are more African-Americans who do not survive the disease.
What is Cancer?
Cancer is when your body cells grow out of control. When this happens the body cannot work the way it should. Most cancers form a lump called a tumor or a growth. Some cancers grow and spread fast. Others grow more slowly. Not all lumps are cancers. Cancerous lumps are sometimes called malignant tumors.
What is Bladder Cancer?
The bladder is where the body stores urine before it leaves the body. Urine is what we call the liquid waste made by the kidneys. The bladder is a hollow organ in the pelvis with flexible, muscular walls. The bladder can get bigger or smaller as it fills with urine. Urine is carried to the bladder through tubes called ureters. When you go to the bathroom, the muscles in your bladder will contract. They then push urine out through a tube called the urethra.
When cells of the bladder grow abnormally, they can become bladder cancer. A person with bladder cancer will have one or more tumors in his/her bladder.
How Does Bladder Cancer Develop and Spread?
The bladder wall has many layers, made up of different types of cells. Most bladder cancers start in the urothelium or transitional epithelium. This is the inside lining of the bladder. Transitional cell carcinoma is cancer that forms in the cells of the urothelium.
Bladder cancer gets worse when it grows into or through other layers of the bladder wall. Over time, the cancer may grow outside the bladder into tissues close by. Bladder cancer may spread to lymph nodes nearby and others farther away. The cancer may reach the bones, the lungs, or the liver and other parts of the body.
Symptoms You Should Not Ignore
Blood in the urine is the most common symptom of bladder cancer. It is generally painless. Often, you cannot see blood in your urine without a microscope. If you can see blood with your naked eye you should tell your healthcare provider immediately. Even if the blood goes away, you should still talk to your doctor about it.
Blood in the urine does not always mean that you have bladder cancer. There are a number of reasons why you may have blood in your urine. You may have an infection or kidney stones. Very small amounts of blood might be normal in some people.
Frequent urination and pain when you pass urine (dysuria) are less common symptoms of bladder cancer. If you have these symptoms, it’s important to see your healthcare provider. Your provider will find out if you have a urinary tract infection or something more serious, like bladder cancer.
People can get bladder cancer when they come into contact with tobacco or other cancer-causing agents. There also are some risks related to genes and certain types of infections. Another known risk factor is a type of radiation beam aimed at the pelvis.
Smoking is a Big Risk Factor
You are more likely to get bladder cancer if you smoke or breathe in tobacco smoke. Smoking tobacco may be the cause of half of all bladder tumors. If you smoke, you are more likely to get bladder cancer than those who have stopped.
Workplace Exposure is another Known Cause
Some things in the workplace may put you at a greater risk for bladder cancer. Contact with chemicals used to make plastics, paints, textiles, leather and rubber may cause bladder cancer.
If your healthcare provider believes you have MIBC, you may be referred to a urologist. Your urologist will perform a full medical history and physical exam. Further tests may be needed to form a diagnosis. If your diagnosed with bladder cancer, you may need additional tests. These tests will find out the stage of your disease. It will also give your doctor an idea of what treatment is best for you.
Tests for MIBC
The following tests most likely will be done:
- Urine cytology. The color and content of your urine will be checked. This test will also look at body cells under a microscope.to test for cancer cells.
- Blood tests: A comprehensive metabolic panel (CMP), which includes kidney and liver function tests will be among the blood tests your doctor will order.
- A Computerized tomography scan (also known as CT or CAT scans) with a bladder scope “cystoscopy” are often good enough to diagnose bladder cancer.
- Cystoscopy: A doctor will use a thin tube that has a light and camera at the end of it (cystoscope) to pass through the urethra into the bladder. It allows your doctor to see inside the bladder cavity. Usually your doctor will use a flexible cystoscope and a local anesthetic for your exam in the office. The doctor will take a tissue sample with a cystoscope in the operating room. Taking the tissue at this time will allow your doctor to look at the cells. The tissue sample will be sent to a laboratory where they will find out the stage of your cancer. This will help with choosing the right treatment.
- Rigid cystoscopy: The scope that the doctor uses when you are put to sleep is not flexible like the one used in the office, but rigid. This means that it is straight and does not bend. This cystoscope is bigger, has a light at the end, and surgical instruments can pass through it. This allows for more extensive work like the transurethral resection of bladder tumor (TURBT) described below.
Diagnosis of bladder cancer is confirmed when the doctor sees the tumor through a cystoscope and during transurethral resection of a bladder tumor (TURBT) described below. You will likely be put to sleep for these exams. At this time your doctor will stage your cancer and try to cut it away. They will also see whether the cancer has spread.
- Transurethral resection of bladder tumor (TURBT). This is a very important procedure for accurate tumor typing, staging and grading. Your doctor can look inside the bladder, take tumor samples and resect (cut away) what he/she sees of your tumor.
- Blue light cystoscopy. For this test, your doctor uses a catheter to place an imaging solution into your bladder through your urethra. The solution is left in the bladder for about an hour. The doctor then uses the cystoscope to inspect the bladder with regular white light and then with blue light. The bladder cancer cells show up better with blue light.
These tests help diagnose and stage bladder cancer.
- Retrograde pyelogram: This test uses x-rays to look at your bladder, ureters and kidneys. The test is done during a cystoscopy.
- Magnetic resonance imaging (MRI): These tests use a powerful magnetic field, radio waves and a computer to produce detailed pictures of the inside of your body.
- If your chest, abdomen or pelvic image results are abnormal or if it is not possible to get a lymph node biopsy, your doctor may order a positron emission tomography (PET) scan.
For the PET scan, you will be given a special drug (a tracer) through your vein or you may inhale or swallow the drug. Your cells will pick up the tracer as it passes through your body. When the scanner passes over the bladder, the tracer allows your doctor to better see where and how much the cancer is growing.
Grading and Staging
What are the Grades and Stages of Muscle Invasive Bladder Cancer?
Grade and stage are two important ways to measure and describe how cancer develops. A tumor grade tells how aggressive the cancer cells are. A tumor stage tells how much the cancer has spread.
Grading is one of the ways to know if the cancer will return. It also tells us how quickly the cancer may grow and/or spread.
Tumors can be low or high grade. High-grade tumor cells are very abnormal, poorly organized and more serious. They are the most aggressive and more likely to grow into the bladder muscle.
The tumor stage tells how much of the bladder tissue has the cancer. Doctors can tell the stage of bladder cancer by taking a small sample of the tumor. This is called a biopsy. A pathologist in a lab examines the sample under a microscope and determines the stage of the cancer.
The stages of bladder cancer are:
- Ta: Tumor on the bladder lining that does not enter the muscle
- Tis: Carcinoma in situ-A high-grade cancer-it looks like a reddish, velvety patch on the bladder lining
- T1: Tumor goes through the bladder lining but does not reach the muscle layer
- T2: Tumor grows into the muscle layer of the bladder
- T3: Tumor goes past the muscle layer into tissues surrounding the bladder
- T4: Tumor has spread to nearby structures such as lymph nodes and the prostate in men or the vagina in females.
What to Expect with MIBC
Muscle invasive bladder cancer is a serious and more advanced stage of bladder cancer. MIBC is when the cancer has grown far into the wall of the bladder (Stages T2 and beyond).
For patients with MIBC, the overall prognosis (how the disease may progress) has not changed in the last 30 years. In patients who undergo cystectomy (surgical removal or partial removal of the bladder), the cancer return rate can be from 20-30% for stage T2. The cancer return rate can be 40% for T3, greater than 50% for T4 and usually higher when lymph nodes are involved. If bladder cancer does recur, it most often will happen within the first two years after bladder surgery.
A cancer diagnosis can be very frightening. However, your doctor and medical team are there to help you.
Your healthcare team will discuss what you must know about all the available forms of treatment. They will tell you about possible risks and the side effects of treatment on your quality of life.
Options and Choices for Treatment
Your options for treatment will depend on how much your cancer has grown.
There are essentially two options:
- Bladder removal (cystectomy) with chemotherapy or without chemotherapy
- Chemotherapy with radiation
Bladder Removal (Cystectomy) Procedures
Neoadjuvant cisplatin-based chemotherapy (NAC)
Bladder removal with chemotherapy increases survival rates for bladder cancer patients. Before removing your bladder, your physician will likely offer neoadjuvant chemotherapy. Adjuvant means, “added to.” If you have MIBC, you may get chemotherapy along with having your bladder removed. Before your doctor does a radical cystectomy (removing all of the bladder), he/she may try to shrink your tumor first with neoadjuvant cisplatin-based chemotherapy (NAC). This means the drug cisplatin or a combination of drugs including cisplatin is first given as chemotherapy and then bladder removal is done afterwards.
Adjuvant chemotherapy means the drug is given after surgery. Your doctor may offer this treatment if it is appropriate for you.
Chemotherapy uses drugs to kill cancer cells. For MIBC, chemotherapy will most likely be given prior to radical (total) cystectomy. As mentioned earlier, neoadjuvant cisplatin-based chemotherapy (NAC) is recommended for treating MIBC.
Drugs are usually given by vein (intravenous). The drugs enter the bloodstream and travel throughout your body.
Typically, doctors offer chemotherapy before bladder removal for best survival rates. However, not everyone is able to have chemotherapy. You may not get chemotherapy if you have poor kidney function, hearing loss, heart problems or other health issues. Some patients may choose not to get chemotherapy before surgery. But, some may still need to have it after surgery depending on the tumor stage. You will probably have your bladder surgery about 6-8 weeks after you have completed chemotherapy.
You may have your chemotherapy treatment in an outpatient part of the hospital, at the doctor’s office or at home. Rarely, you may need to stay in the hospital. Chemotherapy is sometimes given in cycles. Each cycle normally has a treatment period followed by a rest period.
There are side effects to chemotherapy. The side effects depend on which drugs are given and how much is given. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells:
- Blood cells: If chemotherapy drugs lower the levels of healthy blood cells, you’re more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your healthcare team will check for low levels of blood cells. If your levels are low, you may need to stop the chemotherapy or reduce the dose of the drug. There are also medicines that can help your body make new blood cells.
- Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back after treatment. However, your hair color and texture may be different.
- Cells that line the digestive system: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your healthcare team can give you medicines and suggest other ways to help with these problems. Symptoms usually go away when treatment ends.
- Nerve cells: Some drugs used for bladder cancer may cause tingling or numbness in your hands and feet. Your healthcare team can suggest ways to control these side effects.
Surgery to Remove the Bladder (Cystectomy)
For MIBC, because the cancer has grown into the muscle, cystectomy will be needed. Part of or the whole bladder may be removed. As mentioned, before your bladder is removed you will most likely be given neoadjuvant cisplatin-based chemotherapy.
Bladder cancer can spread to the lymph nodes. A pelvic lymph node dissection is used to find out if the cancer has spread beyond the bladder into the lymph nodes. A pelvic lymph node dissection is considered standard of care. Standard of care means that this is the usual treatment for this condition. For a pelvic lymph node dissection, lymph nodes (the fatty tissue surrounding the pelvic blood vessels) are removed. A pelvic lymph node dissection may also be done to treat cancer if it is only in the lymph nodes.
What happens during surgery?
Your bladder can be removed by an open or a robotic approach. It is called “robotic” because computers assist the surgeon during the procedure. In the open approach, the doctor makes one larger incision in the middle of the abdomen to remove the bladder. Open surgery may have a shorter operative time.
For the robotic process, a few smaller incisions are made in the abdomen. Your surgeon puts small instruments through the openings to reach the bladder. Often people have less pain and less blood loss with robotic surgery.
There are several things to think about before choosing open or robotic bladder removal:
- Your body weight
- History of prior surgery
- History of prior radiation
- Where to go for surgery: there is some evidence that complex surgery (such as bladder removal) has better outcomes when performed at Centers of Excellence facilities rather than hospitals, etc.
- Surgeon’s experience: ask your surgeon about his/her familiarity with this type of operation. If you have concerns, get a second opinion.
Radical Cystectomy (removal of the whole bladder)
For MIBC, the most common type of surgery is radical cystectomy. The surgeon removes the entire bladder, nearby lymph nodes and part of the urethra. In men, the surgeon also may remove the prostate. In females, the surgeon may remove the uterus, fallopian tubes, ovaries and vaginal wall. Other nearby tissues may also be removed.
When the entire bladder is removed, the surgeon makes another way for urine to be collected from the kidneys and stored before passing from your body. This is called urinary diversion. Your doctor will discuss the risks of cystectomy and the different methods of urinary diversion.
Partial Cystectomy (removal of part of the bladder)
For MIBC, partial cystectomy is a less likely option as the cancer may be more advanced. Partial cystectomy may be considered in select cases of bladder cancer, in which the tumor is located in a specific part of the bladder and does not involve more than one spot in the bladder. Ask your surgeon whether you are a candidate for this type of surgery.
Bladder removal and urinary diversion
When your bladder is removed or partly removed, your urine will be stored and made to leave your body by a different route. If you have a radical cystectomy, you will need to know about urinary diversion options.
Because the surgeon uses tissue from your intestines for bladder reconstruction, you must have enough bowel tissue for a urinary diversion. Before this is done, your surgeon will go over the procedure. Your doctor will talk about what will be done and the changes you will need to make.
Here are some of the urinary diversion options your surgeon may offer:
- Ileal conduit. An ileal conduit is when a piece of your upper intestine is used it to create an opening (stoma) on the surface of your stomach. The ureters are connected so that the urine leaves your body by the opening. A bag will be attached to collect the urine and you will “dump” the bag several times a day. This is the most simple, and most commonly used diversion after bladder surgery.
- Continent cutaneous reservoir. Your surgeon creates a pouch inside your body and you will learn to use a catheter to remove your urine.
- Orthotopic neobladder. The surgeon creates an internal pouch, much like your bladder, to store urine. Your ureters are connected to this new “bladder” and you are able to empty through your urethra the same way you did before surgery.
In some instances you may need to use a catheter to remove the urine.
Talk with your doctor about your options for a urinary diversion. Having a urinary diversion will greatly impact your quality of life.
Chemotherapy with radiation
Chemotherapy with radiation may be used for bladder preservation (keeping the bladder or parts of it). Bladder preservation may be suggested for select patients where radical cystectomy is not an option or is undesired. The right health circumstances must be present for bladder preservation.
Your surgeon will cut the tumor out (transurethral resection of bladder tumor, TURBT), remove lymph nodes, as well as give you chemotherapy and radiation. This is called a multi-modal approach (several methods). Some drugs that may be used along with radiation are cis-platin, 5-FU and Mitomycin-C. This regimen must be carefully followed up with ongoing cystoscopy exams, cross-sectional imaging (e.g. CT scan) and other procedures to monitor and evaluate the tumor.
For about 30% of patients who use the multi-modal approach to bladder preservation, MIBC will return. It is important for you to have close monitoring by your healthcare team in case the tumor progresses and cystectomy becomes needed.
Radiation alone for MIBC is not an option for controlling the spread of bladder tumors. However, radiation may be offered along with bladder removal.
Radiation as a single form of treatment is not given for MIBC. It is usually done along with chemotherapy and after surgery.Radiation therapy uses high-energy rays to kill cancer cells.
The radiation comes from a large machine. The machine aims beams of radiation at the bladder area in the abdomen. You may go to a hospital or clinic five days a week for several weeks to get radiation therapy. Each treatment session takes about 30 minutes.
Radiation therapy is painless, but it may cause other side effects. Problems with radiation include nausea, vomiting or diarrhea. Also, you may feel very tired during radiation therapy. Your healthcare team can suggest ways to treat or control these side effects.
Bladder Cancer Clinical Trials
What about Clinical Trials?
You may hear about possible clinical trials for your bladder cancer. Clinical trials are research studies that involve people. They 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. Although clinical trials may or not be effective for your particular problem, they present an option to think about. Trials are available for all stages of cancer.
Make sure that you stay in touch with your healthcare provider. You should expect to return to your doctor for quite some time after treatment and surgery.
Follow-up is not the same for everyone. However, continuous observation will include some or all of the following:
- Imaging (e.g. CT scan) about every 3-6 months for 2-3 years; and then annually.
- Laboratory tests may be every 3-6 months for 2-3 years; and then once per year after. Kidney and liver function tests will be a part of these tests.
- Assessment for quality of life issues, such as urinary symptoms and sexual function.
If you had surgery, it takes time to heal. The time needed to recover is different for each person. It is common to feel weak or tired for a while. However, like any other major surgery, bladder surgery may have complications. Older patients and women are more likely to get complications after cystectomy.
There are some things you can do before surgery to help your recovery. If you smoke, try to get help so you can quit before surgery. You also need to make sure you eat right so that your body can heal and can cope with the changes.
Here are some possible side effects from surgery:
- Deep vein thrombosis (DVT). DVT is when a blood clot forms in a deep vein, like the veins in the legs. It sometimes happens after major surgery. Symptoms include swelling, pain and tenderness, often in the back of your legs. Your surgeon will give you medication and devices after surgery to help prevent DVT.
- Gastrointestinal (GI) problems. You may have problems with your bowel function right after surgery. This often happens after abdominal surgery. Your healthcare provider will take steps to monitor bowel function and avoid GI problems.
- Urinary diversion. Urinary diversion following bladder surgery is a big adjustment. You may need to learn how to remove urine from your body with a catheter. There also is potential for leakage from the stoma (opening) that is made to take away urine. Infections related to urinary diversion may occur, as may infections related to the kidneys.
You should learn as much as you can about urinary diversion before having one. Also, before you leave the hospital, your healthcare providers will make sure you get the education you need so you can manage your new way of life.
- Hormonal changes. For females who are not yet menopausal, you may have hot flashes after your ovaries are removed.
- Reproductive health. After surgery a man may not be to have sex. If the prostate was removed a man will not be able to father a child. When the uterus is removed a woman can no longer get pregnant. If the surgeon removes part of a woman’s vagina, then sex may be difficult.
- Sexual dysfunction: Bladder cancer surgery is likely to affect your sex life. If you have a partner, you may be worried about maintaining sexual intimacy and your relationship. It may help you and your partner if you talk about your feelings. You can find other ways to be intimate after you had treatment.
If you do not have a partner, you may want to explore how to manage your dating life after bladder cancer surgery. You and your partner may benefit from the advice of a counselor who specializes in discussing sexual issues.
Your healthcare provider may be able to refer you to medical professionals and counselors who specialize in sexual issues after cancer treatment. You can also find a certified sex therapist near you on the website of the American Association of Sexuality Educators, Counselors and Therapists.
- Managing Pain: You may have pain or discomfort for the first few days following bladder surgery. Medicine can help control your pain. Before surgery, talk to your provider about how to manage your pain. After surgery, your doctor can change the plan if you need more control. Review the Pain Management Fact Sheet for more information.
Try to adopt healthy lifestyle habits. You should exercise, eat a well-balanced diet and stop smoking. Your healthcare provider also may recommend a cancer support group or individual counseling.