| Bladder cancer | Diagnosing bladder cancer | Treatment for bladder cancer |
| Sexuality & bladder cancer | Living with a stoma |
This information has been reviewed by:
Associate Professor Jeremy Millar
Alfred Hospital, William Buckland Radiotherapy Centre
Treatment for superficial bladder cancer
Surgery: transurethral resection
Side effects of intravesical chemotherapy
When cancer can't be cured
Prognosis
Many years of treating cancer patients and testing different treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. Your doctor will advise you on the best treatment for your cancer. This will depend on whether the cancer is superficial (only in the lining of the bladder) or invasive (has spread into the wall of the bladder and beyond). It will also depend on your general health, and what you want.
Superficial bladder cancers are treated with surgery and/or immunotherapy or, sometimes, chemotherapy.
Superficial cancers are removed in a procedure called transurethral resection. You will have a general anaesthetic. The doctor will pass a cystoscope, a slender tube with a lens and a light, through the urethra and into the bladder. The cystoscope lets the doctor see inside the bladder.
Each cancer is removed. The doctor may use electrosurgery. The area around the cancer is cauterised (burned) to prevent excessive bleeding. This sounds severe, but is a safe and common way of removing diseased tissue. Several cancers can be treated at the same time.
After this treatment, regular follow-up cystoscopies are needed (usually every three to four months at first) because the cancer can come back. Follow-up cystoscopies, which do not require cautery, can be carried out in the outpatients department under local anaesthetic. If there is any recurrence of the cancer, it can usually be removed while it is still in the early stages. This will require a separate cystoscopy under general anaesthetic.
Immunotherapy (or biological therapy) is the use of substances that are naturally produced within the body to encourage the immune system to fight disease.
The most common immunotherapy is a vaccine called BCG. When BCG is placed in the bladder, it can be effective for superficial bladder cancers. It is usually not used to treat patients with invasive bladder cancer. BCG contains weakened bacteria that are related to bacteria that cause tuberculosis. This means strict precautions must be followed.
The vaccine seems to work by setting up a reaction in the bladder, which triggers the immune system to reduce or destroy cancer cells. The treatment is done in the urology or oncology outpatients department. It is usually given once a week, for six weeks. The vaccine is given directly into the bladder through a catheter. You will be asked to hold the medicine in your bladder for two hours. During this time the BCG treatment is working on the bladder lining to set up an immune reaction in your body. For the next six hours, when you pass urine, you should sit rather than stand (men as well as women) to avoid splashing on the seat or floor because your urine will still contain BCG.
Men having this treatment can pass on BCG during sex. To protect your partner, you should not have sex for 48 hours after each treatment. Use a condom during sex at other times during the six weeks of treatment. You should also use a condom during sex for six weeks after treatment has ended. If you have questions about this, ask your doctor.
You will need to drink more fluids (not alcohol) in the 24 hours after treatment, to help flush out the vaccine.
It is important to let your doctor know about any other drugs or alternative remedies you are taking. Other drugs could suppress your immune system and interfere with how well the BCG works on your bladder cancer. You may have the treatment at intervals over the next two years. Your doctor will arrange this with you if it is needed.
During the treatment you will probably have side effects such as blood in your urine, needing to pass urine often and pain when you pass urine. These side effects are to be expected and they almost always settle down on their own. However if you have fever, pain in your joints, a cough, a skin rash or severe tiredness, you should tell your doctor. These fever and flu-like symptoms can be treated.
Chemotherapy is the treatment of cancer with anti-cancer drugs. The aim is to destroy all cancer cells while doing the least possible damage to normal cells. The drugs work by stopping cancer cells from growing and reproducing themselves.
For people with superficial bladder cancer, the drugs can be injected directly into the bladder through a catheter. This is called intravesical chemotherapy. It puts the drugs in direct contact with the cancer and the lining of the bladder. There are fewer side effects compared with having chemotherapy into a vein or by mouth. This is because very little gets out of the bladder and into the blood to affect the rest of the body. You may have one injection, or weekly injections over about six weeks.
If you have chemotherapy directly into the bladder, you may have cystitis. You may also need to pass urine more often than normal and feel some ‘burning' when you do so.
Surgery is the most common treatment for invasive bladder cancer. Radiotherapy is an alternative treatment for invasive bladder cancer. In some cases chemotherapy may be added to either surgery or radiotherapy.
Sometimes the cancer may be too large to be removed by the cystoscope, or may have started to grow through the bladder wall. In these cases, part or all of the bladder may have to be removed.
If part of the bladder is removed, the operation is called a partial cystectomy. After this operation you will be able to pass urine as usual, but your bladder will be smaller and hold less urine, so you will need to pass urine more often. Not many people have a type of bladder cancer that can be treated with partial cystectomy.
If the cancer has started to spread beyond the bladder, the doctor can often stop further spread by removing the bladder and organs near the bladder. The operation is called a radical cystectomy. In women, the uterus, ovaries and Fallopian tubes and sometimes the part of the vagina that contains the urethra may also be removed. If this happens, you will go through menopause. This means you will not be able to have children and will probably have symptoms such as hot flushes. If this is of concern, talk to your doctor before surgery about the options that may be available to you.
In men, the prostate and sometimes the urethra need to be removed, since the cancer can recur in these organs. Removing the bladder can affect the nerves needed to get an erection, so your sex life may change. See the section on ‘Sexuality and cancer'. If all of the bladder is removed in a radical cystectomy, a new storage place for urine is created (see the section on ‘Urostomy').
When you wake up from the operation you will have several tubes in your body. You will have an intravenous drip to give you fluid and medication. You will have tubes in your abdomen to drain away fluid from the operation site.
You will probably feel very tired for some weeks. You will have some pain or discomfort in the areas where organs were removed and you have stitches. Tell the doctor or nurse if you have pain-don't wait for it to become bad before asking for pain relievers.
You will be in hospital for 10 to 14 days. You may see a physiotherapist, who will explain how you may begin exercising again. If you have a stoma (see urostomy section below), a stomal therapy nurse will explain how to care for it and tell you about support services.
The most common way of making a new storage place for urine is to form a urostomy. While you are under a general anaesthetic, the doctor will remove a piece of your small bowel, join the two ureters to one end of it and bring the other, open end out through the skin of your abdomen. This is called an ileal conduit: the piece of small bowel (ileum) acts as a drainpipe to take the urine from the ureters and bring it to the surface of the abdomen (see next page). The bowel will be rejoined after the piece to be used for the urostomy has been removed.
A flat, watertight bag will be placed over the opening on the abdomen (stoma) to collect the urine. It is kept in place with a special type of glue. The bag will fill with urine in the same way as the bladder and will need to be emptied as needed. The stomal therapy nurse will advise you how to care for your stoma.
Another way of making a storage place for urine is to use a piece of the bowel to make a new bladder. This usually means you can urinate as usual, without the need for a stoma. The operation is known as bladder reconstruction (or neobladder), and it can be done in a number of ways.
Usually your doctor will remove a piece of your bowel, make it into a balloon-shaped sac and stitch it to the top of your urethra. The ureters are stitched into this new bladder so that urine drains directly into it from the kidneys. You may then pass urine in the usual way through the urethra.
For some people, a catheter is sometimes needed to drain the bladder because the pouch doesn't empty completely. The new bladder is emptied by flexing your abdominal muscles, but you will need to remember to empty it as you will have lost the nerves that tell you when your bladder is full. Sometimes this nerve loss can lead to slight incontinence, especially when you are asleep.
Bladder reconstruction is not suitable for everyone. Discuss this with your doctor: there is a list of questions at the end of this booklet that may help.
Radiotherapy treats cancer by using radiation to destroy cancer cells. The radiation can be targeted to cancer sites in your body. Treatment is carefully planned to do as little harm as possible to your normal body tissues.
Radiotherapy may be used instead of surgery to treat invasive bladder cancer to try to avoid removing the bladder. Sometimes chemotherapy is given with radiotherapy so the cells are made more sensitive to the radiotherapy. The treatment is given in a radiotherapy department. The course is usually in five sessions from Monday to Friday, for several weeks. The length of your treatment will depend on the type and size of the cancer and whether the aim is cure or relief of symptoms.
Common side effects of radiotherapy are fatigue (tiredness), nausea (which can be helped by medication) and loss of appetite. It can also cause problems in the area treated. Radiotherapy to the pelvis may irritate the bowel and cause diarrhoea and, occasionally, soreness around the anus. It may also cause mild cystitis, and make you pass urine more often or experience a burning feeling when you pass urine.
In some people, the bowel or bladder may be permanently affected by the radiotherapy. If this happens then more frequent and looser bowel motions and bleeding may occur. This is uncommon.
Skin in the treatment area may become pink after four or five weeks of treatment. From the start of your treatment, you will need to take care washing and avoid wearing clothing that rubs. Check with your doctor or nurse before using any talcs and lotions. If needed, a member of your radiotherapy team will talk with you about how to deal with the side effects of radiotherapy. Ask if you are unsure.
Our coping with radiotherapy page discusses ways of managing side effects.
This is the treatment of cancer with anti-cancer drugs. The aim is to destroy all cancer cells while doing the least possible damage to normal cells. The drugs work by stopping cancer cells from growing and reproducing themselves. Chemotherapy may be helpful to some patients with invasive bladder cancer. The drugs are given intravenously (by injection into a vein). This sort of chemotherapy is sometimes called systemic chemotherapy, to distinguish it from intravesical chemotherapy.
You may have intravenous chemotherapy:
This is done so that the drugs can circulate in the blood and reach the cancer cells that might have spread to other parts of the body. A course of several drugs is given over a few days. This is then repeated every few weeks for several months.
Some drugs used in chemotherapy can cause side effects. They may include feeling sick (nausea), vomiting, feeling unwell and tired, and some thinning or loss of hair from your body and head. Generally, these side effects are temporary and can be prevented or reduced. Some drugs can cause longer-term or permanent side effects. Steps will be taken by your doctors to monitor these effects.
Our coping with chemotherapy page discusses ways of managing side effects.
If your cancer has spread and it is not possible to cure it by surgery, your doctor may still recommend treatment. In this case, treatment may help relieve any symptoms, can make you feel better and may allow you to live longer. Whether or not you choose to have anti-cancer treatment, symptoms can still be controlled. For example, if you have pain, there are effective treatments for this.
General practitioners, specialists and palliative care teams in hospitals all play important roles in helping people with cancer. For further information, contact the Cancer Council Helpline on 13 11 20 or Palliative Care Victoria on 9662 9644. Our advanced cancer section has information for people with advanced cancer and their carers.
Bladder cancer can be effectively treated if it is found early, before it spreads outside the bladder. You will need to talk with your doctor about your own prognosis. Your medical history is unique, so you will need to discuss with someone who knows your medical history the treatment options that are best for you.
People who have been treated for bladder cancer need regular check-ups, including having cystoscopies and x-rays. This allows your doctors to monitor your health. You may find this reassuring after your treatment. Follow-up may continue for several years.
After the treatment, give yourself time. Finding out you have cancer and having surgery, chemotherapy and/or radiotherapy are all tiring. You need to give yourself time to get your strength back. If you are responsible for the house, you will need some help for a while. If you work outside the home, you will need to ease back into it slowly, rather than rushing back the week after leaving hospital.
This means you might have to remind your family and friends that for a while you won't be fit enough to do all your usual activities. If you have any problems or notice any new symptoms in between these times, let your doctor know as soon as possible.
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