Finding new treatment options for bladder cancer

Mr Ahmed Ali

Consultant Urological Surgeon, Frimley Health NHS Foundation Trust

Mr Ben Ayres

Consultant Urological Surgeon, St George’s University Hospitals NHS Foundation Trust

Bladder cancer affects over 10,000 people a year in the UK. A minimally invasive treatment offers hope to patients who wish to preserve their bladder or those who cannot undergo major surgery.

 While bladder cancer is the fourth most common cancer in men behind prostate, colorectal and lung cancer, about 80% of cases are the highly treatable non-muscle invasive bladder cancer (NMIBC), with a survival rate around 90%.

Consultant urological surgeons Ahmed Ali and Ben Ayres are keen to see increased public awareness of related risk factors – such as smoking – and symptoms, particularly blood in the urine or needing to pass urine more often, so patients can visit their GP and be referred to specialists for investigation and treatment.

Risk of recurrence

Mr Ali, from Frimley Health NHS Foundation Trust in Surrey, also underlines the need for a proactive approach and for men over 60 – who are four times more likely to get bladder cancer than women – to do a urine test to spot for early signs of the disease. “A urine sample could lead us to detecting it before it is too late,” he adds. “Many bladder cancers are curable; we can treat while preserving the bladder, so we do not have to perform radical surgery.”

Treatment for bladder cancer is endoscopic excision, following CT scan and a camera investigation, to remove the cancer when at the non-invasive stage. The disease does have raised levels of recurrence but to avoid that, chemotherapy or immunotherapy is administered into the bladder to stimulate the body’s response to fight the cancer.

Many bladder cancers are curable; we can treat while preserving the bladder, so we do not have to perform radical surgery.

However, while BCG has been an effective treatment since the mid- 1970s for higher risk patients, it fails in up to 40-50% of cases, meaning patients may have to have their bladder removed.

While that surgery has risks and lifestyle impacts for patients, Mr Ayres, from St George’s University Hospitals NHS Foundation Trust in London, says: “With modern techniques, robotic surgery and enhanced recovery programmes, cystectomy is an operation that more people get through without significant complications.”

Searching for alternative solutions

However, in patients where cystectomy could be particularly risky, those unwilling to have surgery, or for immuno-compromised patients where BCG is not suitable, consultants need to look for new solutions. Trials are ongoing in this area, and Synergo® is one of a few potential options.

Designed to help eradicate cancer and preserve bladder function, Synergo® delivers a tri-modality of Radiofrequency-Induced Thermochemotherapy and features a dedicated applicator incorporating a miniature antenna which generates microwave non-ionising energy to the bladder tissue. The same applicator instills cold chemotherapy into the bladder.

In 2014 researchers discovered that radio-frequency (RF) has cancer-lethal effects. Its combination with chemotherapy makes the drug more infiltrative selectively into cancer cells. The RF also heats the bladder to above normal temperature for improved outcomes. In 2020 researchers also revealed this trimodality is synergistic.

The hour-long therapy is delivered using a lubricating gel containing local anaesthetic, in an outpatient setting over a set of six to eight weekly sessions. A few more subsequent sessions may be given every couple of months in order to retain a tumour-free status.

Improving long term outcomes

Mr Ayres adds: “On the whole, it is well tolerated by patients, and if they do not respond to it, they may still have a cystectomy.

Case selection of patients is very important. In our experience about two-thirds of patients who have failed BCG and have this treatment remain disease-free at 2 years, and 40-50 percent have a good response long-term – some up to 10 years – with follow-up.”

As with all treatments there are advantages and disadvantages which must be discussed with one’s consultant. A cystectomy is a lengthy operation, requires high dependency post-operative care, and may greatly impact patients’ lifestyles and quality of life when their bladder is removed. In many cases also adjacent organs might need to be removed. From an oncological perspective, however, such radical surgery is considered the definitive cancer treatment.

Conversely, Synergo® consists of a series of treatments, with regular follow-ups, with some risk of the cancer coming back. If that happens the cancer may need to be removed again. Some of the patients, might be advised to have their bladder removed. It may be a last hopeful option for patients who wish to preserve their bladder or those who cannot undergo major surgery.