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Homepage – Forum Forums Muscle Invasive Bladder Cancer Chemo Therapy or Remove Bladder.

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    I am scheduled for radiation and chemo starting in about 2 weeks. My decision over bladder removal and ostomy procedure.

    My urologist is urging me for the removal as opposed to radiation treatment because the cancer is muscle invasive and says if the radiation and chemo therapy does not work, he won’t be able to remove the bladder because of

    too much damage to surrounding tissues. In other words, I have to make an either or decision which procedure to make.

    Anyone heard of this and been thru the same predicament?


    Hello nwood5580,

    Have a look at Manon’s post under the title Upcoming Bladder Removal.  He/She is having the bladder removed, but receiving 4 months of Chemo prior to.  You may want to consider asking for a 2nd opinion from another Urologist; or, tell your Urologist what you’ve discovered in the Bladder Cancer Forum, and therefore you’re wondering if Chemo might still be an option prior to removal of the bladder.

    Keep in mind every patient is different and what is recommended for one patient may not be appropriate for another.

    My best,


    Hi Nightingale:

    I think nwood5580 is having to make a choice between doing the bladder preservation therapy of chemo/radiation versus radical cystectomy.  nwood 5580 did I interpret your post correctly?  If I did, I second Nightingale’s suggestion of seeking a second opinion and also suggest reaching out to BCC to see if you can get connected with a peer support volunteer that has done the bladder preservation route.

    If you do go for a second opinion, I suggest asking the following:

    1) Do you agree with my other urologist that the bladder preservation radiation will damage too much tissue to make bladder removal possible should the bladder preservation protcol not work?

    2) What level of risk to my survival does the choice of bladder preservation present in my case?

    3) If bladder removal is possible after the bladder preservation protocol fails, what additional risks/complications could I be facing during the radical cystectomy surgery because of having had the radiation treatment?  You really need a clear picture of this to make sure that the bladder preservation is worth the risks.

    If it is determined that the risks of trying the bladder preservation protcol are reasonable and you want to pursue it, you have to ask yourself how you will feel should the bladder preservation protocol fail.  Everyone is different.  Some people will fight literally “tooth and nail” and try all options first before consenting to a radical cystectomy. That gives them the feeling of satisfaction that they did everything possible to save their bladder and it helps them deal psychologically to accept the inevitable. Others just say “To heck with it, I just want to get the surgery over and done with.”  People in that camp often view it as the safer option and less strenuous.  I think that you will have to do some deep consideration to see which camp you fall into.

    No matter which option you choose, there are pros and cons and considerable risks. As mentioned, I do strongly recommend talking to someone at BCC if there is an available peer support volunteer and having either a further conversation with your current urologist and/or getting that second opinion.  Best of luck.  Please let us know how it goes.   (((HUGS)))


    Thanks MarySue!  Appreciate your input.




    MarySue, thankyou.

    I’m new to forum and am seeking help.   My father whom is 81 and in good health was recently diagnosed with T3.   We are weighing our options as surgeon has recommended chemo then removal of bladder but did tell us its not impossible to do removal after radiation and chemo just harder.    With the little research we have done we see that their is really not a difference between removal of bladder and just going with Chemo and radiation as a form of treatment with percentages of survival and life expectancy with this diagnoses.      Right now we are thinking of the just doing chemo and radiation as we are concerned with recovery for my Dad from the surgery and the fact he already will be going through Chemo we figure why put more potential for risk related to surgery.   We are seeking to understand from people that have opted for Chemo and Radiation how they got through it and was it successful at treating the cancer.

    Appreciate any help people can provide.  Bless you all


    Hi Scubamike,

    I think the dilemma you and your father are facing is not uncommon.  Bladder cancer is said to be the disease of elderly.  30% (335 ) of newly diagnosed  male bladder cancer patients are 80+ (1155 males) according to BC Cancer Agency (2018).   I have read 20-25% of newly diagnosed are muscle invasive bladder cancer, so over 70 patients who are 80+ years old are diagnosed with muscle invasive bladder cancers each year in BC alone.  It is likely that  many of those senior will be facing the same question; to remove the bladder or not to.  In this sense, you are not alone in facing the dilemma.   Because every patient is different, in terms of type of bladder cancer the patient has and physical condition conditions are different, and patient’s preference may be different, it is difficult to make a blank statement the removal – radical cystectomy (RC) or the combination of chemotherapy and radiation (CR) is more suitable.

    1.  I think it is inaccurate to state that there is not a difference between RC and CR in terms of progression free survival (metastasis free) (PFS) or  survival rate (OS).   Very selective patients with Trimodal Therapy have shown to have similar outcome compared to RC.   Trimodal therapy (TMT) which consists of three key treatment steps, i.e. a complete resection of all visible tumour, chemotherapy and radiation.   A complete resection will be difficult if the tumor is big, at difficult location to resect or already too deep in the bladder wall.   There are other few criteria which the patient needs to meet to qualify for TMT, so the patient will likely have similar progression free survival or survival rate with RC.  So, in UT affiliated hospitals, only one 1 or 2 patients are selected each month for TMT according to Dr. Kulkarni of University of Toronto.    In Ontario, 2018, 1165 (male and female) 80+ years old were diagnose with bladder cancers.  So,  about 230 patients who were 80+ years old  were diagnosed  muscle invasive bladder cancers.   It indicates less than 10% of those patients are treated with TMT in UT affiliated hospitals.  I do not know how many of those 230 patients were treated with TMT in other hospitals, such as University of Ottawa affiliated hospitals.  Anyway, 80% of muscle invasive bladder cancer patients who are 80+ years old seem not to qualify for TMT treatment program offered in those major hospitals.

    Your dad was diagnosed with T3.  The tumor has progressed past the muscle tissue (T2) and reached the fat layer  (T3) of the bladder.     Because the wall of bladder is only 2-4 mm thickness, which consists of epithelial tissue, connective tissue, muscle tissue and fat,  the complete resection without perforating bladder wall becomes harder as the tumor progresses deep into the bladder wall.  For this reason patients with T2 are preferred candidates for TMT.    I have Dr. Kulkarni saying that though it is rare even T4 patients can be considered for TMT the tumor response so well to neoadjuvant chemotherapy.   So, your dad with T3 is not completed excluded from TMT treatment.

    I am not certain but if chemo radiation you are mentioning is TMT or chemo radiation without the step of the complete resection of all visible tumor be cause the tumor is already in T3 stage.

    Except those who qualified for TMT, in general RC gives better progression free survival rate and over all survival rate.   I am not fan of using the qualitative term like better , worse.  So, below are information of which some I have heard from urologist and some from internet with quantitative comparisons between RC and CR.

    1. A urologist I know said the oldest patient he performed RC is over 90 years old.

    2. The fact your father was recommended for RC and will be going through is that his European Cooperative Oncology Group (ECOG) Performance Status is probably  Grade 0, healthy enough to bear the burden of chemotherapy and surgery.

    ECOG Grade 0 : Fully active, able to carry on all pre-disease performance without restriction

    ECOG Grade 1:  Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

    ECOG Grade 2: Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours

    ECOG Grad  3:  Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours

    ECOG Grade 4: Completely disabled. Cannot carry on any selfcare. Totally confined to bed or  chair

    Comparing the result of RC and Radiation Therapy for elderly

    A study by mainly Department of Urology  of University of Montreal  2021

    The conclusion  : In elderly and very elderly patients, radical cystectomy is associated with virtually half the cancer specific mortality  rate than radiotherapy, regardless of concomitant chemotherapy administration (chemo radiation).    Patients who had RC lived twice longer than patients who had radiation therapy only or chemotherapy + radiation.

    The group investigated the cancer data base through  The Surveillance, Epidemiology, and End Results (SEER) Program provides information on cancer statistics in an effort to reduce the cancer burden among the U.S. population.

    Age 75-79,  1808 patients used RC and 855 patients used Radiation Therapy.

    5 year cancer specific morality (CMT) was 22.0 % in RC only vs 49% in RT only.    5 year CMT was 28.3%  in Chemotherapy + RC  vs 44.3% with TMT.

    Age 80-89,  1551 patients used RC and 2018 patients used RT.

    5 year cancer specific morality (CMT) was 24.02 % in RC only vs 48.9% in RT only.    5 year CMT was 19.6%  in Chemotherapy + RC  vs 44.2% with TMT.

    It is noted that younger senior patients (75-79) chose RC over RT  2:1.    Older seniors (80-89) chose RC  and RT  at almost the same ration – 1551 patients chose RC vs 2018 patients chose RT

    In terms of how to mitigate the risk of RC surgery,  I will post it next.





    Hi Scubamike,

    I would like first clarify that the study by University of Montreal distinguish from those who had radiation therapy was given the treatment with the intention to cure (cancer free) or for  palliative care.  It might have made the cancer specific mortality rate with radiation therapy higher than if only it included the radiation treatment with intention to cure.   It is noted that 1551 (43.5%) out of 3589 patients age 80+ received RC.    If RC is very risky for elderly patients, I would not think 43.5% of patients age 80+ had chosen RC.

    Lets explore actual clinical studies the risk of  RC for elderly patients.

    • UK(2017)  – a single hospital Department of Urology, Pinderfields General Hospital, Mid-Yorkshire Hospitals Trust, Wakefield, West Yorkshire, UK   Retrospective study of patients who had RC in 2013-2015. 51 patients were 74 years old and younger and 30 patients were 75 years old and older.  The mean age was 70.7 years old (36-85).  RC in patients aged ≥75 years has similar perioperative morbidity when compared with younger patients and can be offered in selected elderly patients. Thus, age should not be an absolute contraindication for RC.  The 30-day mortality rate was 4% for those aged <75 years and 6.6% for those aged ≥75 years, with overall perioperative complication rates of 57% vs 66%, respectively.  Most complications were minor. The conclusion  RC in patients aged ≥75 years has similar perioperative morbidity when compared with younger patients and can be offered in selected elderly patients. Thus, age should not be an absolute contraindication for RC.
    • Poland (2021) – Age and risk of major complications in patients undergoing radical cystectomy for muscle invasive bladder cancer    Dept of General Oncologic Urology, Nicolaus Copernicus Hospital, Poland   :  434 patients with MIBC who underwent radical cystectomy between 2012 and 2016, and  classified them into three age groups: < 65, 66–74, and ≥ 75 years .   Age was not a significant predictor of major complications, long hospital stay, or blood loss.  Older age was associated with shorter surgery times.   Therefore, , older age alone should not be contraindication to this operation.
    • Germany (2018)  – Predicting 90-day and long-term mortality in octogenarians undergoing radical cystectomy.   1184 consecutive patients who underwent radical cystectomy for high risk superficial or muscle-invasive bladder were split into two groups (age < 80 years versus 80 years or older).  Only age predicted 90-day mortality in patients aged 80 years or older. Concerning 90-day mortality, chronological age provided prognostic information whereas comorbidity did not.  Cumulative mortality rate from bladder cancer at 5 years was 30% for < 80 years old and 42% for 80+ years old. and at 10 years 38% for <80 years old and 42% for 80+ years old. Cystectomy should not be denied in octogenarians by numeric comorbidity. Concerning 90-day mortality, in octogenarians selected for radical cystectomy chronological age could have greater impact than numeric comorbidity.
    • US (2001) –  Department of Urologic Surgery –  Vanderbilt University, Tennessee – The journal of urology :RADICAL CYSTECTOMY IS SAFE IN ELDERLY PATIENTS AT HIGH RISK.   382 patients had RC between 1994-2000.  44 were elderly and at high risk, as defined by age 75 years old and greater and American Society of Anesthesiologists classification 3 or greater. We examined postoperative care, perioperative minor/major complications, the mortality rate and the need for rehospitalization.  Median age was 77.5 years (74-87). Median hospitalization was 7 days (range 4-20 days).  70% of patients were transferred directly to the general urology floor after the surgery, while 30% was required for cardiac monitoring. 4 required surgical intensive care unit admission.  Minor and major complications developed in 10 (22.7%) and 2 (4.5%) cases, respectively. No patients died in the perioperative period and 4 patients were hospitalized within 6 months of discharge home. The conclusion Our results support the safety of radical cystectomy in elderly patients at high risk. Acceptable perioperative morbidity and mortality may be achieved without routine intensive monitoring postoperatively.

    How to mitigate the risk for RC surgery.

    1. Choose less risk urinary diversion because it takes less operation time.  The IC surgery takes 2-4 hours.       Neobladder takes 4-8 hours.    Note Ileal conduit (IC) is incontinent and will require external bag to collect urine via stoma on belly.

    2. Choose standard lymph node resection vs extended lymph node resection.   Dr. Black of VGH has stopped extended lymph node resection after the clinical trial found out there were no benefits of extended lymph node resection vs standard, and extended lymph node resection causes more complications, including death.

    3.  Choose the surgeon who has done many RC surgeries of the urinary diversion of your choice.

    4.  If possible, choose the hospital which has implemented  Enhanced Recovery After Surgery (ERAS) protocol.  ERAS protocol is supposed to help patient recover faster.

    5.  If possible, choose the hospital which performs many RC surgeries in a year.

    6.  If eligible,  get neoadjuvant chemotherapy treatment.    Neoadjuvant chemotherapy can downstage the existing tumor and control microscopic cancer cells which might have escaped from bladder, resulting in improvement in survival rate.

    May be other people can add or make correction to the list.





    The following is a recent post at another discussion forum on bladder cancer.  It is just one example, but the case is similar to your father’s situation.

    My father was 84 years old (now almost 94!) when he had his RC/IC. He too had stage 3 bladder cancer. His was high grade, aggressive in nature (squamous cell type) but no metastasis. He did not have chemo because his type of cancer was apparently not responsive to it. So I can not give any advice or anecdotal information on that. Instead, my father went straight to RC surgery. He too was healthy and active. The surgery was not as bad as he anticipated. He did not report much pain after 2 days. I helped him change his bag every 4 days when we returned home and then a month later he started changing it himself. Don’t get me wrong, it was a challenging journey for him and our family. It took a toll on his body (25 pound weight loss), his stamina for doing simple things and he was completely and understandably overwhelmed at times. Surprisingly, my father had a great attitude though and was just so happy to get rid of the cancer, and accepted this new normal.


    Thanks Joe, for sharing your father’s story. The beautiful thing is that he is now 10 years older after getting rid of the cancerous bladder. Here’s wishing him, you and your family a wonderful 2024.

    My Best!


    Hi Nightingale,

    Finally after meeting with my urologist and because of possible complications , I received a first round of Chemo Therapy.  Then when came time to remove the bladder I was told there would be to many complications and so I was told they could try the “Trimodal” therapy which is a combination of Chemo and radio therapy so I went with it.  I was told by my oncologist, radio oncologist and urologist that the treatment was as sufficient and good as a bladder removal.   Finished my Trimodal therapy in October.  Had a scan in December which showed no evidence of cancer or metastasic cancer.  Got a cystoscopy in January and again NED.  So it worked for now and i’m hoping this crab never comes back.  Hope this helps.




    Hi Manon,
    Thanks for the update. I am keeping my fingers crossed for you. I hope nwood sees your post, if it’s not too late. Please keep us posted on your progress.

    My Best,


    My Dad was diagnosed with stage 2, high grade, muscle invasive BC as well and just finished round one of chemo.

    The urologist we saw is also strongly recommending bladder removal because of the high grade diagnosis but we’ll be re-evaluating after 4 rounds of chemo.  My Dad is 77 and would like to avoid that extensive a surgery at all costs.  When we met with the radiologist, he said that its possible that instead of surgery, my Dad could do radiation, combined with a lower dose of chemo and that seems to be where my Dad is leaning.  The second option makes me nervous because of the chance of recurrence but its my Dad who has to go through with it and if he doesn’t want surgery, then he won’t be having surgery.  We’ve decided to focus on getting through chemo first and keep our minds open to what might come next.  Everything depends on how well the cancer responds to the chemo treatment.  He started chemo last Wednesday (received 3 hours of cisplatin and gemcitabine) and finished the round this Wednesday with an hour of gemcitabine.  I have to say, he and I are both a little surprised at how he’s feeling.   He was able to work a few days last week before fatigue set in and was also able to work a few days this week and so far, no nausea.  I understand that the side effects are cumulative (my Mom went through cancer treatments 14 years ago), but we are so far relieved and will ride out this little wave of positivity for as long as it lasts.


    Hi TJW,
    Thanks so much for sharing your Dad’s story. Sound like there is hope for him not having to go through surgery. I certainly hope that is the case and have all body parts crossed for you and your dad.

    Thanks again for sharing some good news.

    My best,

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