Bladder cancer - Treatment for bladder cancer

The treatment options for bladder cancer largely depend on how advanced the cancer is.

Treatments usually differ between early stage, non-muscle-invasive bladder cancer and more advanced muscle-invasive bladder cancer.

Multidisciplinary teams (MDTs)

All hospitals use multidisciplinary teams (MDTs) to treat bladder cancer. These are teams of specialists that work together to make decisions about the best way to proceed with your treatment.

Members of your MDT may include:

a urologist – a surgeon specialising in treating conditions affecting the urinary tract
a clinical oncologist – a specialist in chemotherapy and radiotherapy
a pathologist – a specialist in diseased tissue
a radiologist – a specialist in detecting disease using imaging techniques
a specialist cancer nurse – who will usually be your first point of contact with the rest of the team

Deciding what treatment is best for you can be difficult. Your MDT will make recommendations, but remember that the final decision is yours.

Before discussing your treatment options, you may find it useful to write a list of questions to ask your MDT.

Non-muscle-invasive bladder cancer

Your treatment plan

If you have been diagnosed with non-muscle-invasive bladder cancer (stages CIS, Ta and T1), your recommended treatment plan will depend on the risk of the cancer returning or spreading beyond the lining of your bladder.

This risk is calculated using a series of factors, including:

the number of tumours present in your bladder
whether the tumours are larger than 3cm (one inch) in diameter
whether you have had bladder cancer before
the grade of the cancer cells

See diagnosing bladder cancer for more information about the staging and grading of the condition.

If the risk of your cancer returning or spreading is low, treatment will involve surgery to remove the tumours followed by a single dose of chemotherapy into your bladder.

If the risk of your cancer returning or spreading is moderate, you may be given a longer course of chemotherapy into your bladder after you've had surgery.

If the risk of your cancer returning or spreading is high, you may be given a course of Bacillus Calmette-Guérin (BCG) treatment into your bladder after you've had surgery.

These treatments are discussed in more detail below.

Surgery

The standard surgical treatment for non-muscle-invasive bladder cancer is known as transurethral resection of a bladder tumour (TURBT) procedure. In most cases this can be performed at the same time as a biopsy.

TURBT is carried out under general anaesthetic. The surgeon uses an instrument called a cystoscope to locate the visible tumours and cuts them away from the lining of the bladder. The wounds are then sealed (cauterised) using a mild electric current.

If you experience significant bleeding afterwards, a flexible tube called a catheter may be inserted into your urethra and passed up into your bladder. The catheter will be used to drain away any blood and debris from your bladder and may be kept in place for several days.

Most people are able to leave hospital less than 48 hours after having TURBT and are able to resume normal physical activity within two weeks.

Chemotherapy

After surgery, you may be given a dose of chemotherapy directly into your bladder. This will be after you have recovered from the effects of the general anaesthetic.

A different type of chemotherapy (intravesical chemotherapy) is used directly into your bladder using a catheter (rather than affecting the whole body). The solution is kept in your bladder for about an hour before being drained away.

Some residue of the chemotherapy medication may be left in your urine, which could severely irritate your skin. It helps if you urinate while sitting down and that you are careful not to splash yourself or the toilet seat. After passing urine, wash the skin around your genitals with soap and water.

Side effects of intravesical chemotherapy can include a skin rash or irritation and inflammation of the bladder lining. This can cause a frequent need to urinate and pain when urinating. However, this should pass within a few days. You may also feel very tired or develop a rash.

If your cancer is at a low risk of spreading, you should not need additional chemotherapy treatment. However, if there is a moderate or high risk of the cancer spreading, you may be given additional courses of chemotherapy, usually once a week over six weeks.

If you are sexually active, it is important that you use a barrier method of contraception, such as a condom, while you are having intravesical chemotherapy. This is because the medication may be present in your semen or vaginal fluids, which can cause irritation.

You also shouldn't try to get pregnant or father a child while having intravesical chemotherapy, as the medication can increase the risk of having a child with birth defects.

Bacillus Calmette-Guérin (BCG) treatment

After surgery, you may also be treated with a variant of the BCG vaccine. This is used to help prevent recurrence of bladder cancer when there is a high risk of it returning.

The BCG vaccine was originally used to treat tuberculosis (TB), but it has also proved to be an effective treatment against bladder cancer. Exactly how the BCG vaccine works is still unclear.

The BCG vaccine is given in the same way as intravesical chemotherapy. The vaccine is passed into your bladder through a catheter and left in your bladder for two hours before being drained away.

As with intravesical chemotherapy, you should take precautions such as sitting down while urinating to ensure that urine does not get onto your skin or the toilet seat.

Most people require weekly treatments over a six-week period. Depending on your circumstances, maintenance therapy may also be recommended. This involves receiving further doses of the BCG once a week for three weeks, with six month intervals. Maintenance therapy usually lasts for three years.

Chemotherapy is usually preferred to BCG treatment because the side effects are less severe. Common side effects of BCG can include:

a frequent need to urinate
pain when urinating
blood in your urine (haematuria)
flu-like symptoms, such as tiredness, fever and aching
urinary tract infections

Muscle-invasive bladder cancer

Your treatment plan

The recommended treatment plan for muscle-invasive bladder cancer will depend on how far the cancer has spread. See diagnosing bladder cancer for more information about staging.

With T2 and T3 bladder cancer, treatment aims to cure the condition if possible, or at least control it for a long time.

There is only a small chance of a cure for T4 bladder cancer, but treatment may be able to control the symptoms and slow the spread of the cancer.

The different treatment options are outlined below.

Surgery

The most widely used type of surgery for muscle-invasive bladder cancer is a radical cystectomy.

This removes the entire bladder as well as nearby lymph nodes, part of the urethra, the prostate (in men), and the cervix and womb (in women).

During a radical cystectomy, your surgeon will also create an alternative way for urine to leave your body. This is known as urinary diversion.

After surgery many men will be unable to get or maintain an erection (erectile dysfunction). This is because the operation can damage the nerves responsible for getting an erection. However, treatments for erectile dysfunction are usually available.

See the complications of bladder cancer surgery for more information about urinary diversion and sexual problems after surgery.

Radiotherapy

Radiotherapy uses pulses of radiation to destroy cancerous cells and is an alternative treatment option for muscle-invasive bladder cancer.

Radiotherapy can be used:

as a primary treatment to try to cure bladder cancer – this may be a preferred option if your general health is thought to be too poor to withstand the effects of surgery
to help control the symptoms in cases of incurable bladder cancer – known as palliative radiotherapy

External radiotherapy

Radiotherapy used to shrink tumours and achieve a cure is given by a machine that beams the radiation at the bladder (external radiotherapy).

Sessions of external radiotherapy for bladder cancer are usually given on a daily basis for five days a week over the course of four to seven weeks. Each session lasts for about 10 to 15 minutes.

As well as destroying cancerous cells, radiotherapy can also damage healthy cells, which means it can cause a number of side effects. These include:

diarrhoea
inflammation of the bladder (cystitis)
tightening of the vagina (in women), which can make having sex painful
erectile dysfunction (in men)
loss of pubic hair
infertility
tiredness
incontinence

Most of these side effects should pass a few weeks after your treatment finishes, although there is a chance they will be permanent.

The fact that radiation has been directed at your pelvis will usually mean that you will be infertile for the rest of your life. This is not a problem for most people who undergo radiotherapy, as they are too old to have children by the time they have treatment.

Palliative radiotherapy

Palliative radiotherapy – where the aim is to relieve symptoms – is usually only given for short periods, so it will not usually cause side effects. If there are side effects, they will only last for a short time.

However, it can take time for palliative radiotherapy to be effective, so you might feel worse before you start feeling better.

Surgery or radiotherapy?

Your MDT may recommend a specific treatment because of your individual circumstances.

For example, someone with a small bladder or many existing urinary symptoms is better suited to surgery. Someone who has a single bladder tumour with normal bladder function is better suited for treatments that preserve the bladder.

However, your input is also important, so you should discuss which treatment is best for you with your MDT.

There are pros and cons of both surgery and radiotherapy.

The pros of having a radical cystectomy include:

treatment is carried out in one go
you will not need regular cystoscopies after treatment, although other less invasive tests may be needed

The cons of having a radical cystectomy include:

it can take up to three months to fully recover
there is a risk of general surgical complications, such as pain, infection and bleeding
there is a risk of complications from the use of general anaesthetic
an alternative way of passing urine out of your body will need to be created, which may involve an external bag
there is a high risk of erectile dysfunction in men (estimated at around 90%) as a result of nerve damage
after surgery some women may find sex uncomfortable, as their vagina may be smaller
there is a small chance of a fatal complication, such as a heart attack, stroke or deep vein thrombosis (DVT)

The pros of having radiotherapy include:

there is no need to have surgery, which is often an important consideration for people who are in poor health
your bladder function may not be affected, as your bladder is not removed
there is less chance of causing erectile dysfunction (around 30%)

The cons of having radiotherapy include:

you will require regular sessions of radiotherapy for four to seven weeks
short-term side effects are common, such as diarrhoea, tiredness and inflammation of the bladder (cystitis)
there is a small chance that the bladder could be permanently damaged, which could lead to urinary incontinence
women may experience a narrowed vagina, making sex difficult and uncomfortable

Chemotherapy

In some cases chemotherapy may be used to treat muscle-invasive bladder cancer.

However, this is different from the intravesical chemotherapy used to treat non-muscle-invasive bladder cancer. Instead of medication being put directly into your bladder, it is put into a vein in your arm.

This is called intravenous chemotherapy and can be used:

before radiotherapy and surgery to shrink the size of any tumours
in combination with radiotherapy before surgery (chemoradiation)
to slow the spread of incurable advanced bladder cancer (palliative chemotherapy)

As yet there is not enough evidence to say whether chemotherapy is an effective treatment when it is given after surgery to prevent the cancer returning, so it usually only used this way as part of a clinical trial. See clinical trials for bladder cancer for more information.

Chemotherapy is usually given over a few consecutive days at first. You will then have a few weeks off to allow your body to recover before the treatment begins again. This cycle will be repeated for a few months.

As the chemotherapy medication is being injected into your blood, you will experience a wider range of side effects than if you were having intravesical chemotherapy. These side effects should stop after the treatment has finished.

Chemotherapy weakens your immune system, making you more vulnerable to infection. It is therefore important to report any symptoms of a potential infection, such as a high temperature, persistent cough or reddening of the skin, to your MDT. Avoid close contact with people who are known to have an infection.

Other side effects of chemotherapy can include:

nausea
vomiting
hair loss
lack of appetite
tiredness

Follow-up

If your treatment did not involve removing your bladder, there is a risk that the cancer will return.

The risk of bladder cancer returning after treatment is generally higher in cases of superficial bladder cancer compared to muscle-invasive bladder cancer, and can be as high as 80% in some cases of particularly high risk superficial bladder cancer.

Your risk is also increased if you have:

multiple tumours
a tumour(s) larger than 3cm (one inch) in diameter
a previous history of recurring bladder cancer

It is therefore recommended that you attend regular follow-up appointments so you can be monitored.

Your MDT will be able to provide more advice and recommendations regarding the timing of your follow-ups.