Treatment for bladder cancer

Tuesday 31 May, 2011
Reviewed by: Dr Farshad Foroudi, Radiation Oncologist, Peter MacCallum Cancer Centre; Dr Mario Guerrieri, Radiation Oncologist, Radiation Oncology Victoria; Mr Shomik Sengupta, Urologist, Freemason's Medical Centre

On this page: Treatment for superficial bladder cancer | Surgery: transurethral resection | Intravesical chemotherapy | Surgery: cystectomy | Urostomy | Radiotherapy | Chemotherapy | When cancer can't be cured | Prognosis | Recovery and follow-up care

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.

Treatment for superficial bladder cancer

Superficial bladder cancers are treated with surgery and/or immunotherapy or, sometimes, chemotherapy.

Surgery: transurethral resection

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 will be removed. The doctor may use electrosurgery or laser surgery. The area around the cancer is cauterised (burned) to prevent excessive bleeding and destroy cancer cells. This 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, may be carried out 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: BCG

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 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 the tuberculosis bacteria. This means strict precautions are needed.

The BCG seems to work by setting up a reaction in the bladder that 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 BCG is put directly into the bladder through a catheter. You will be asked to hold the BCG in your bladder for two hours. 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, please ask your doctor.

You will need to drink more fluids (not alcohol) in the 24 hours after treatment, to help flush out the BCG.

It is important to let your doctor know about any medicines, vitamins, herbs or other alternative treatments you are taking. These 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 for you if it is needed.

Side effects of immunotherapy

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.  A low-grade fever or flu-like symptoms also commonly occur, especially in the first day or two after treatment. 

These side effects are to be expected and they almost always settle down on their own, or with some paracetamol and fluids.  However if you have a high fever, pain in your joints, a cough, a skin rash or severe tiredness, you should tell your doctor. These fever and flu-like symptoms may indicate a more serious reaction that needs to be treated.

Intravesical chemotherapy

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 put 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.

Side effects of intravesical chemotherapy

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.

Treatment for invasive bladder cancer

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.

Surgery: cystectomy

If the cancer is too large, or has started to grow through the bladder wall it may not be suitable for removal by cystoscope,  In these cases, part of or the entire 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, Fallopian tubes and sometimes the part of the vagina that contains the urethra may also be removed.  This will affect you sexually and also affect your fertility.  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 our section on ‘Sexuality and cancer'. If the bladder is removed in a radical cystectomy, a new storage place for urine is created.

After the operation

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 living with a stoma), a stomal therapy nurse will explain how to care for it and tell you about support services.

Urostomy

The most common way of making a new storage place for urine is to form a urostomy.

During your surgery, after the bladder has been removed, the doctor will take a piece of your small bowel, join it to the two ureters at one end 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.  The bowel is reconnected so it can continue to work as usual.

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.

Before your operation the doctor or nurse will carefully plan the position of your stoma, so that your bag will stay in place whether you are sitting, standing or moving about. The stoma is usually formed on the abdomen, to the right of the navel (belly button), but there are many things that must be taken into account when planning the site. Wrinkles, scars and prominent underlying bones must be avoided, as placing the stoma near them may cause leakage later on. Sometimes the stoma can be tailored to a person's particular need, for example a golfer may prefer a stoma placed so that it doesn't interfere with playing their sport.

The stomal therapy nurse will advise you how to care for your stoma.

Ileal conduit with stoma after cystectomy 

Ileal conduit with stoma after cystectomy

Bladder reconstruction

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 urologist 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.

The neobladder does not work like a normal bladder. You will need some months to learn how to use it. You will learn how to use your muscles in a new way to empty the neobladder. You will need to remember to empty it as you will have lost sensation from the nerves that tell you when your bladder is full.

Sometimes the neobladder doesn't empty completely and people use a catheter to drain the urine. 

Some people with a neobladder have some incontinence, especially when they are asleep. 

Bladder reconstruction is not suitable for everyone. Discuss this with your doctor: see our list of questions, which may help.

Radiotherapy

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 while aiming to maintain your natural bladder. Sometimes chemotherapy is given with radiotherapy so the cells are made more sensitive to the radiotherapy.

You will have the treatment in a radiotherapy department. The course is usually in five sessions from Monday to Friday, for up to six and a half 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.

Side effects of radiotherapy

Common side effects during a course of radiotherapy are fatigue (tiredness) and skin redness. 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, you may have more frequent and looser bowel motions and bleeding, although 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 when washing and avoid wearing clothing that rubs the skin. 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 side effects. Ask if you are unsure.

Our coping with radiotherapy page discusses ways of managing side effects.  

Chemotherapy

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 by injection into a vein. This sort of chemotherapy (intravesical chemotherapy) is sometimes called systemic chemotherapy.

You may have intravenous chemotherapy:

  • before surgery, to shrink the cancer and make it easier to operate on
  • after surgery, if it is thought there is a high risk of the cancer coming back
  • with radiotherapy, to improve the control of the cancer
  • if the cancer has already spread, to alleviate cancer symptoms.

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.

Side effects of chemotherapy

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. Your doctor will see you regularly in follow-up appointments to check whether you have these side effects. If you have any problems or notice any new symptoms in between appointments, let your doctor know as soon as possible.

Our coping with chemotherapy page discusses ways of managing side effects.

When cancer can't be cured

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.  

Prognosis

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.

Recovery and follow-up care

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.  If you have any problems or notice any new symptoms in between these times, let your doctor know as soon as possible.

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 a house and family, 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.

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 for a while.

Complementary and alternative cancer therapies

It's common for people with cancer to seek out complementary and alternative treatments. Many people feel it gives them a greater sense of control over their illness, that it's ‘natural' and low-risk, or they just want to try everything that seems promising.

Complementary therapies include massage, meditation, acupuncture and other relaxation methods, which are used along with medical treatments. Alternative therapies are unproven remedies, including some herbal and dietary remedies, which are used instead of medical treatment. Some of these have been tested scientifically and found not to be effective or even to be harmful.

Some complementary therapies are useful in helping people to cope with the challenges of having cancer and cancer treatment. However, some alternative therapies are harmful, especially if:

  • you use them instead of medical treatment
  • you use herbs or other remedies that make your medical treatment less effective
  • you spend a lot of time and money on alternative remedies that simply don't work.

Be aware that a lot of unproven remedies are advertised on the Internet and elsewhere without any control or regulation. Before choosing an alternative remedy, discuss it with your doctor or a cancer nurse at the Cancer Council Helpline.

For more information we recommend you read the following:

You can find out about what scientific research has been done into specific herbs, supplements and other products on the Memorial Sloan-Kettering website. The US National Center for Complementary and Alternative Medicines (NCCAM) and Quackwatch are also reliable websites.

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