Bladder cancer - Treatment 

Surgery

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

A TURBT is performed under general anaesthetic. The surgeon will use a cystoscope to find all the visible tumours and will then cut them away from the lining of the bladder, through the cystoscope.

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

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

After having a TURBT, most people are able to leave hospital within 48 hours, and are able to resume normal physical activity within two weeks.

Chemotherapy

Once a TURBT is complete, you will be given one or more courses of chemotherapy. The first course of chemotherapy will be given immediately after surgery once you have recovered from the effects of the general anaesthetic.

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

There may be some residue of the chemotherapy medication left in your urine, so when going to the toilet it is important not to splash yourself or the toilet seat with urine as it could irritate your skin. After passing urine, wash the skin around your genitals with soap and water. Your cancer nurse will be able to provide you with more advice about these issues.

The advantage of this technique is that as the chemotherapy medication is only in your bladder, and because it is not injected into your blood (intravenous chemotherapy), 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
• 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.

Bacillus Calmette-Guérin (BCG) vaccine

The BCG vaccine is used to treat high-risk cases of non-invasive bladder cancer in order to reduce the risk of the cancer returning.

The BCG vaccine was originally designed 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 the immune system begins to target and destroy any remaining cancer cells.

The BCG vaccine is administered in the same way as intravesical chemotherapy. A liquidised version of the vaccine is passed into your bladder. You will need to keep the vaccine in your bladder for two hours, after which it is drained away.

The precautions regarding not splashing yourself, or the toilet seat, with urine also apply to the BCG vaccine.

Most people require weekly treatment over six weeks. Depending on your circumstances, maintenance therapy may also be recommended. This involves you 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

Less common side effects include:

• a high temperature (fever) of above 39C (102.2F)
• skin rash
• a general sense of feeling unwell

Inform your MDT if the side effects become troublesome because additional treatments for them are available.

Invasive bladder cancer

Your treatment plan

The recommended treatment plan for invasive bladder cancer will depend on how far the cancer has spread.

Health professionals use a staging system to describe the spread of bladder cancer. The stages are outlined below.

• T2a – where the cancer has spread to the inner half of the muscles surrounding the bladder.
• T2b – where the cancer has spread to the outer half of the muscles.
• T3a – where the cancer has spread into the layer of fat surrounding the muscle, but can only be seen with a microscope.
• T3b – where the cancer has spread into the layer of fat surrounding the muscle and can be seen without using a microscope.
• T4a – where the cancer has spread beyond the bladder into nearby organs, such as the prostate, vagina or womb.
• T4b – where the cancer has spread to the wall of the pelvis or abdomen.

In cases of T2, T3 and T4a bladder cancer, a cure may be possible using a combination of chemotherapy and radiotherapy, and also surgery, to remove some, or all, of the bladder.

In cases of T4b bladder cancer, the prospect for 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

Surgery for invasive bladder cancer involves removing some or all of the bladder. This is known as a cystectomy.

There are two types of cystectomy:

• a partial cystectomy – where only part of the bladder is removed
• a radical cystectomy – where all of the bladder is removed as well as near-by lymph nodes, part of the urethra, the prostate (in men), and the cervix and womb (in women)

A radical cystectomy carries the obvious drawback of the loss of normal bladder function. Further surgery will be required to compensate for the loss of bladder function by creating an alternative way for urine to leave your body. This type of surgery is known as urinary diversion.

Men also have the risk of not being able to get or maintain an erection (erectile dysfunction) after a radical cystectomy because the operation can sometimes damage the nerves that are responsible for this ability. However, treatments are available for erectile dysfunction.

More information about urinary diversion and erectile dysfunction is provided in the complications section.

The main advantage of a radical cystectomy is that it has a greater track record of success in preventing the return of the cancer and extending life span. Therefore, it is usually the treatment of choice for invasive bladder cancer.

An exception may be made in cases of T2a and T2b bladder cancer where there is only one tumour present in the bladder.

Discuss the advantages and disadvantages of both techniques with your MDT before making a decision about your treatment.

Radiotherapy

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

There are three main ways that it can be used to treat bladder cancer, explained below.

• Radiotherapy can be used before a cystectomy is carried out in an attempt to shrink the tumour(s) in order to increase the chances of the operation being successful.
• Radiotherapy can be used as a primary treatment to try to cure bladder cancer. This may be a preferred option if your general state of health is thought to be too poor to withstand the effects of a cystectomy.
• Radiotherapy can be used to help control symptoms in cases of incurable bladder cancer. This is known as palliative radiotherapy.

External radiotherapy

Radiotherapy that is used to shrink tumours and/or to 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 of radiotherapy lasts about 10-15 minutes.

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

• diarrhoea
• an increased need to urinate
• pain when urinating
• 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 usually means 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 such as IVF. However, this will not be possible if you are a woman and you have a radical cystectomy because your 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 is usually only given for a few minutes, so it will not usually cause side effects or, if there are any side effects, they will only last for a short time.

Chemotherapy

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

• before radiotherapy and surgery in order to shrink the size of any tumours
• in combination with radiotherapy before surgery (known as 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 in order to prevent the return of the cancer.

Intravenous chemotherapy is used to treat 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, and then you have a week off to allow your body to recover from the effects of the treatment. This cycle is then 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.
The side effects of chemotherapy can include:

• nausea
• vomiting
• hair loss
• lack of appetite
• tiredness

Report any signs of an infection to your MDT immediately. For example, if your temperature rises above 38C (100.5F) or you suddenly start to feel unwell, let your MDT know.