Chemotherapy for Metastatic Bladder Cancer

Chemotherapy is often used as the main treatment for bladder cancer that has spread to other parts of your body. Chemo drugs can shrink tumors, slow the cancer's growth, keep symptoms under control, and help you live longer. Because newer chemo drugs are less toxic, you might have fewer side effects, too.

While the survival rate for untreated metastatic bladder cancer is three to six months, chemotherapy can extend your life up to about 15 months. Chemo based on the drug cisplatin is considered first-line treatment, meaning most health care practitioners try it first. Up to three-quarters of people who have cisplatin-based chemo have some improvement. Other chemo treatments can be effective, too, with expected results somewhat less positive.

The main chemo treatments for metastatic bladder cancer combine chemo drugs that target cancer in different ways:

• GemCis: Gemcitabine and cisplatin. Many cancer centers consider it the best course of treatment because of relatively high extended survival (14 months, per a Canadian study).
• MVAC: Methotrexate, vinblastine, doxorubicin, and cisplatin. Its projected lengthened survival is a little higher than that of GemCis, at 15 months, but it's more toxic.
• GemCarbo: Gemcitabine and carboplatin. It might be used if you don’t tolerate cisplatin well, though extended survival isn’t as high, at nine months.

At each chemo session, you'll receive chemo drugs through a slender, short tube that goes into a vein in your arm. Chemo is usually given in weekly cycles. These might range from every week to every four weeks, with a period of rest in between to complete each cycle. Treatments usually last for six cycles.

Rest and have a light meal before treatment. Pack a bag with things to help you feel more comfortable: clothing for layering; socks; a book, laptop, or tablet to help keep you busy; photos of loved ones; pleasant music; and nutritious snacks. When you get home, drink lots of fluids and try to walk every day. Stock items to help with side effects, such as ginger ale or dietary supplements your doctor has OK'd.

You will go to the location where you'll receive chemo. This is usually a hospital outpatient unit, a clinic, or your doctor's office. You might need to complete some bloodwork, though sometimes it'll be done before your visit. Your care team will assess your health for safety and double check the chemo drug choices. Throughout the procedure, they'll watch for side effects and modify treatment if needed. Many people feel fine in the first few hours after chemo, with side effects showing up four to six hours later.

Often, chemo side effects are worse about 12 hours later, or the day after treatment. This is because as chemo kills cancer cells, it kills good cells, too. The side effects that tend to kick in the earliest are nausea, fatigue, and mouth sores. Hair loss usually starts to happen two to three weeks after chemo starts. Your body will be at highest risk of infection about seven to 12 days after your chemo treatment. This happens because chemo lowers your supply of white blood cells, which are your main infection fighters.

The most common side effects of chemo are:

• Fatigue
• Nausea and vomiting
• Mouth sores
• Increased risk of infections
• Hair loss

The most common chemo side effect is fatigue. Your body's hard work and lower blood counts after treatment can make you feel exhausted. Plan how you'll boost your energy levels, such as prioritizing daily activities, doing some light exercise, such as walking and resting, and taking short naps every day. You can also eat healthy foods and ask your care team for help creating a wellness plan.

Up to 80% of people who have chemo will have nausea and vomiting at some time. You can counter it by:

• Taking meds your doctor prescribes
• Planning small, light meals throughout the day. Don't eat right before or after treatment.
• Choosing foods that are easy to digest. Avoid greasy, fatty, or spicy foods.
• Taking in lots of fluids. Try cold drinks, flat soda, and juice without pulp.
• Resting after you eat to let your stomach settle

It’s very common to have hair loss during the first several weeks of starting chemo. Chemo zeroes in on cells that grow quickly, such as hair follicles. Some people try cold capping, also known as scalp cooling, which cuts blood flow to the scalp so the follicles might have less chemo damage. Results vary, but cold capping can reduce hair loss by 50%. Also:

• Plan ahead. Buy an attractive wig, hats, head wraps, or scarves.
• Treat your hair gently. Avoid harsh products or styling tools.
• Wear a cotton cap or other head covering outside to protect your scalp.

Mouth sores are also common with chemo. They can make eating painful. To avoid irritating them:

• See your dentist before treatment. Other oral health problems can make chemo side effects worse. Stay on top of dental visits throughout treatment.
• Eat non-irritating, soft food served at room temperature.
• Avoid carbonated drinks, crunchy foods, or anything acidic.
• Limit chocolate, coffee, and alcohol. 

Because chemo lowers your white blood cell count, you'll have fewer cells that can fend off infection. Help guard your weakened immune system:

• If your doctor prescribes them, get shots or patches to raise your white cell blood count.
• Stay current on vaccinations.
• Steer clear of people who are sick. Wear a mask if something’s going around.
• Wash your hands often, wear clean, dry clothes, and tend to wounds right away.

Other approaches are often combined with chemo. One clinical trial found combining the immunotherapy drug atezolizumab with GemCis slowed the spread of metastatic bladder cancer and targeted tumors with a high level of the protein PD-L1. Another showed the immunotherapy drug nivolumab combined with GemCis extended survival by three months. The immunotherapy drug avelumab, when used after chemo to maintain the effects, has been shown to increase survival by as much as seven months.

Sometimes, surgery will be done to remove lymph nodes affected by metastatic bladder cancer or to ease symptoms. Radiation therapy also might be combined with chemo to ease symptoms and pain.

Other than managing side effects as they happen, you can make your chemo cycles a little better if you:

• Get lots of rest, but give your days some structure by keeping to a routine. 
• Stay hydrated and eat when you can.
• Lean on your family, friends, and your care team for support.