Treatment for bladder cancer


Many hospitals use multidisciplinary teams (MDTs) to treat bladder cancer.


MDTs are teams of specialists that work together to make decisions about the best way to proceed with your treatment.


Members of your MDT will probably include a:


  • surgeon

  • clinical oncologist (a specialist in the non-surgical treatment of cancer)

  • pathologist (a specialist in diseased tissue)

  • radiologist (a specialist in radiotherapy)

  • urologist (a doctor who specialises in treating conditions that affect the urinary tract)

  • social worker

  • psychologist

  • 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.


Non-muscle invasive bladder cancer


Your treatment plan


If you have been diagnosed with non-muscle invasive bladder cancer, 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 that are present in your bladder

  • whether the tumours are larger than 3cm (one inch) in diameter

  • whether you have had bladder cancer before

  • whether the tumours are limited to your bladder lining, or whether they’ve started spreading beyond the lining

  • the grade of the cancer cells

The grade of the cancer cells describes how aggressively they are likely to grow and spread, with low grade being the least aggressive and high grade being the most aggressive.


If the risk of your cancer returning or spreading is low, your recommended treatment plan will usually be surgery to remove the tumours followed by a course of chemotherapy that is placed inside your bladder.


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


If the risk of your cancer returning or spreading is high, as well as surgery and chemotherapy you will be given an additional medication known as the Bacillus Calmette-Guérin (BCG) vaccine.


Surgery, chemotherapy and the BCG vaccine for non-muscle invasive bladder cancer are discussed in more detail below.


Surgery


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


A TUR is carried out under general anaesthetic. The surgeon will use an instrument called a cystoscope to locate all of the visible tumours and will then cut them away from the lining of the bladder.


Once the tumour(s) have been removed, any bleeding can be stopped using a mild electric current to seal (cauterise) the remaining wound.


If you experience significant bleeding, a thin, 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. It may need to be kept in place for several days.


Most people are able to leave hospital within 48 hours of having a TUR and are able to resume normal physical activity within two weeks.


Chemotherapy


After having surgery, you will be given one or more courses of chemotherapy. You will have your first course after surgery has been completed and you have recovered from the effects of the general anaesthetic.


A type of chemotherapy called intravesical chemotherapy is used. It involves placing a liquid solution of chemotherapy medication directly into your bladder using a catheter. The solution will be kept in your bladder for about an hour before being drained away.


Some residue of the chemotherapy medication may be left in your urine, so be careful not to splash yourself or the toilet seat with urine because it could irritate your skin. After passing urine, wash the skin around your genitals with soap and water.


The advantage of using intravesical chemotherapy is that because the chemotherapy medication is placed inside your bladder, rather than being injected into your blood so you will not experience the side effects that are most commonly associated with chemotherapy, such as nausea, fatigue and hair loss.


The most common side effect of intravesical chemotherapy is irritation and inflammation of the bladder lining. This can sometimes cause a frequent need to urinate and pain when urinating. These side effects should pass within a few days.


If your cancer is low-risk, you should not require any additional treatment. However, if your cancer is medium- or high-risk, you will be given additional courses of chemotherapy, usually once a week over six weeks.


If you have sex, it is important that you use contraception while you are having intravesical chemotherapy because the medication that is used can temporarily affect the quality of a man’s sperm and a woman’s eggs. This increases the risk of birth defects.


Read more about chemotherapy.


Bacillus Calmette-Guérin (BCG) vaccine


The BCG vaccine is used to treat high-risk cases of non-muscle invasive bladder cancer in order to reduce the risk of the cancer 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. It appears to stimulate the immune system in such a way that it begins to target and destroy any remaining cancer cells.


The BCG vaccine is given in the same way as intravesical chemotherapy. A liquidised version of the vaccine is passed into your bladder. The vaccine will be left in your bladder for two hours before being drained away.


The above precaution about not splashing yourself or the toilet seat with urine also applies to the BCG vaccine.


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 every six months, with a series of three-weekly doses.


Maintenance therapy usually lasts for three years.


Common side effects of the BCG include:


  • a frequent need to urinate

  • pain when urinating

  • blood in your urine (haematureia)

You should inform your MDT if the side effects become particularly troublesome because additional treatments are available for them.


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, T3 and T4a bladder cancer, a cure may be possible using a combination of chemotherapy, radiotherapy and surgery to remove some, or all, of your bladder.


With T4b bladder cancer, the prospect of achieving a cure is slim. However, it is possible to control the symptoms and slow the spread of the cancer using chemotherapy and radiotherapy, and sometimes surgery.


Surgery


The most widely used type of surgery in bladder cancer is a radical cystectomy.


This is where all of your bladder is removed as well as nearby lymph nodes, part of the urethra, the prostate (in men), and the cervix and womb (in women).


A radical cystectomy carries the obvious disadvantage of a loss of normal bladder function. To compensate for this, further surgery will be required to create an alternative way for urine to leave your body. This type of surgery is known as urinary diversion.


Men also have the risk of being unable to get or maintain an erection (erectile dysfunction) after having a radical cystectomy. This is because the operation can sometimes damage the nerves that are responsible for getting an erection. However, treatments for erectile dysfunction are available.


Read more information about the complications of bladder cancer surgery.


Radiotherapy


Radiotherapy is an alternative treatment option for muscle-invasive bladder cancer.


Radiotherapy is a type of treatment that uses pulses of radiation to destroy cancerous cells.


There are three main ways that radiotherapy can be used to treat bladder cancer which are explained below. Radiotherapy can be used:


before you have a cystectomy, to shrink the tumour(s) and increase the chances of the operation being successful

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 a cystectomy

to help control the symptoms in cases of incurable bladder cancer; known as palliative radiotherapy


External radiotherapy


Radiotherapy that is 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 different side effects. These include:


  • diarrhoea

  • inflammation of the bladder (cystitis),

  • which can cause pain when urinating as well as an increased need to urinate

  • tightening of the vagina (in women), which can make having sex difficult and painful

  • erectile dysfunction (in men)

  • loss of pubic hair

  • infertility

With the exception of infertility, these side effects should pass a few weeks after your treatment finishes. The fact that radiation has been directed at your pelvis will usually mean that you will be infertile for the rest of your life. If you still want to have children, discuss possible treatment options with your MDT.


For example, men can have samples of their sperm frozen and women can have their eggs frozen for use in future artificial insemination treatments or IVF. However, this will not be possible for women who have a radical cystectomy because their womb will be removed.


External radiotherapy will not make you radioactive and you will pose no danger to other people, including children and pregnant women.


Palliative radiotherapy


Palliative radiotherapy, where the aim is to relieve symptoms rather than achieve a complete cure, is usually only given for a few minutes, so it will not usually cause side effects. If there are any side effects, they will only last for a short time.


Read more about radiotherapy.


Surgery or radiotherapy?


Your MDT may recommend that you use a specific treatment option due to your individual circumstances.


For example, surgery is often recommended in cases where bladder cancer is more advanced because it is usually more effective in preventing the cancer from returning. Radiotherapy is often recommended for people who are too ill to withstand the effects of surgery.


However, in many cases, the decision about whether to have surgery or radiotherapy will be a matter of personal preference. Both treatment options have their own set of pros and cons.


The pros of having a radical cystectomy include:


  • You avoid the side effects of radiotherapy, such as diarrhoea or an increased need to urinate.

  • You don’t need to attend as many follow-up appointments as you would if you had radiotherapy.

The cons of having a radical cystectomy include:


  • Further surgery will be required to create a new way of passing urine out of your body.

  • It can take up to three months to fully recover from the effects of bladder surgery.

  • There is a relatively high risk of erectile dysfunction in men (estimated at around 90%) and reduced sexual pleasure in women (just under half of women will experience this) after surgery.

  • There’s around a 1 in 50 chance of a radical cystectomy causing a fatal complication, such as a heart attack or stroke.

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.

  • It is usually possible to maintain normal bladder function.

  • There is less chance of causing erectile dysfunction (estimated at around 30% compared with 90% for a radical cystectomy).

The cons of having radiotherapy include:


  • You will require regular sessions of radiotherapy for four-to-seven weeks.

  • There is an increased risk of the cancer returning which may mean that you would still need to have surgery to remove your bladder.

  • Side effects, such as diarrhoea, tiredness and inflammation of the bladder (cystitis) are common.

  • There is a chance that the bladder could be permanently damaged, which could lead to a loss of bladder control and the involuntary leakage of urine (urinary incontinence).

Before making a decision about which treatment to have, you should fully discuss the pros and cons of each treatment option with your MDT.


Chemotherapy


There are three main ways that chemotherapy can be used to treat muscle-invasive bladder cancer. It 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

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.


Intravenous chemotherapy is used to treat muscle-invasive bladder cancer, which involves a combination of different chemotherapy medications being injected into your vein.


Chemotherapy is usually given two days a week for several weeks. You will then have a week off to allow your body to recover from the effects of the treatment. This cycle will then be repeated for a few months.


A total course of chemotherapy can last for up to six 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 (where chemotherapy medication is placed directly into your bladder).


The side effects of chemotherapy can include:


  • nausea

  • vomiting

  • hair loss

  • lack of appetite

  • tiredness

These side effects should stop after the treatment has finished. Chemotherapy can also weaken 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.


Read more about chemotherapy.


Follow-up


If your treatment did not involve removing all of your bladder (which is usually the case with non-muscle invasive bladder cancer and some cases of muscle-invasive bladder cancer), there is a risk that the cancer will return. This can be as high as 80% in high-risk cases.


Factors that increase the risk of the cancer returning include:


  • having multiple tumours

  • having a tumour(s) that are larger than 3cm (one inch) in diameter

  • having a previous history of recurring bladder cancer

Due to this risk, it is recommended that you have regular urinary cytography tests or cystoscopies to assess the state of your bladder. The frequency of these tests will depend on how likely your MDT thinks it is that the cancer will return.


If the risk of the cancer returning is thought to be relatively low, you will probably only need to have a cystoscopy three months after your treatment is completed. If the results of this prove negative, a further cystoscopy will be carried out nine months later and then yearly for five years.


If the risk of the cancer returning is thought to be high, you will probably need to have a cystoscopy and a urinary cytography every three months for two years. If the results of both tests prove negative, the frequency can then be reduced to every six months for five years and followed by yearly testing after that date.


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


If you have had your bladder removed, there is still a chance that cancerous cells could return else where in your body, such as in your lungs, abdomen or pelvis. It may be recommended that you attend annual appointments so that your lungs can be checked using a chest X-ray and your abdomen and pelvis checked using a computer tomography (CT) scan.



Treatment for bladder cancer

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