Treatment for muscle invasive bladder cancer

Monday 1 February, 2016

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On this page: Surgery | Systemic chemotherapyRadiotherapyPalliative treatment 


When bladder cancer has invaded the muscle, the most common treatment is surgery. Other treatments, such as chemotherapy, may be combined with surgery. Some bladder cancers may be treated with only a combination of chemotherapy and radiotherapy.

Surgery

Surgery is the preferred treatment for muscle-invasive disease, or for cancer that has invaded the lamina propria and has not responded to BCG. The main operation is the removal of the bladder (cystectomy). This can be done in different ways.

Removing the whole bladder (radical cystectomy)

A radical cystectomy is the most common operation for muscle- invasive bladder cancer. The whole bladder and nearby lymph nodes are removed. In men, the prostate, urethra and seminal vesicles may also be removed. In women, the urethra, uterus, ovaries, fallopian tubes and a portion of the vagina are often removed.

Surgical techniques

It may be possible to remove the bladder using keyhole surgery, also known as minimally invasive or laparoscopic surgery. In some cases, the surgeon will be assisted by the robotic da Vinci system.

In keyhole surgery, the surgeon makes a few small cuts in the abdomen to insert the instruments, rather than one large cut (open technique). Recovery is usually faster with keyhole surgery, but open surgery is still recommended in some situations.

Removing part of the bladder (partial cystectomy)

This type of operation is not suitable for most types of bladder cancer, so it is less common. A partial cystectomy removes only the bladder tumour and a border of healthy tissue around it.

Side effects of cystectomy

After a radical cystectomy, you will probably stay in hospital for 1–2 weeks. You will have tubes in your body to give you fluids and to drain the operation area. You may have pain after the surgery and need pain relief for a few days.

After a partial cystectomy, your bladder will be smaller and hold less urine, so you may need to pass urine more often.

If you have a radical cystectomy, removing the bladder and surrounding organs will change the way your body functions. In men, the nerves needed to get an erection are likely to be affected. Women who have their reproductive organs removed will go through menopause if they have not already. These changes may affect how you feel about your appearance, sex life and fertility.

Replacing the bladder

With the bladder removed, you will need to store urine in another way. This is called a urinary diversion.

There are various options for surgically reconstructing the bladder after a cystectomy – for more information, see living with a bladder reconstruction.

Urothelial carcinoma of the ureter or kidney

Urothelial carcinoma is the most common form of bladder cancer, but occasionally it can occur in a ureter or kidney.

Much of this section will be relevant if you have been diagnosed with urothelial cancer of the kidney or ureter. Symptoms include blood in the urine and back pain. Many of the same tests will be used for diagnosis, but instead of a cystoscopy, you will have a ureteroscopy, which uses a thin instrument with a light to examine the ureter and kidney.

The most common treatment is surgery to remove the kidney, ureter and part of the bladder (nephroureterectomy). Sometimes, only part of the ureter or kidney needs to be removed (segmental resection). Chemotherapy or immunotherapy may be used after surgery.

Systemic chemotherapy

Chemotherapy is the treatment of cancer with anti-cancer (cytotoxic) drugs. It aims to kill cancer cells while doing the least possible damage to healthy cells.

For muscle-invasive bladder cancer, drugs are given by injection into a vein (intravenously). As the drugs circulate in the blood, they travel throughout the body. This type of chemotherapy is called systemic chemotherapy. It is different to the intravesical chemotherapy used for non-muscle-invasive bladder cancer, which is delivered directly to the bladder.

You may have systemic chemotherapy:

  • before surgery, to shrink the cancer and make it easier to remove (neoadjuvant chemotherapy)
  • after surgery, if there is a high risk of the cancer coming back (adjuvant chemotherapy)
  • with radiotherapy, if surgery is not an option (sometimes called chemoradiation)
  • to treat bladder cancer that has spread to other parts of the body.

Systemic chemotherapy is given as a course of drugs over a few days. The drugs are given every few weeks for several months.

Side effects of systemic chemotherapy

Systemic chemotherapy drugs circulate in the body and can affect normal, healthy cells as well as cancer cells. This can lead to side effects, which may include:

  • nausea and vomiting
  • fatigue
  • itchy skin
  • mouth sores
  • hair loss.

Generally, side effects are temporary. However, sometimes the effects are long-term or permanent. Some side effects can be eased with prescription drugs; talk to your doctor about this.

During chemotherapy, you may be more prone to infections. If you develop a temperature over 38°C, contact your doctor or go to the emergency department at your nearest hospital.

More on chemotherapy

Radiotherapy

Radiotherapy uses high energy x-rays to kill cancer cells or injure them so they cannot multiply. It may be used instead of surgery to treat muscle-invasive bladder cancer without removing the bladder.

On its own, radiotherapy may not cure the cancer. Sometimes, chemotherapy is given with radiotherapy to make the cells more sensitive to the radiation. This may be called chemoradiation.

During a radiotherapy session, you will lie on an examination table and a machine will direct the radiotherapy towards your body. The treatment is painless and can’t be seen or felt. Radiotherapy is usually given from Monday to Friday for several weeks. You will meet with the radiation oncology team to plan your treatment.

Side effects of radiotherapy

Radiotherapy for bladder cancer can cause temporary side effects, including:

  • skin redness and soreness
  • burning when you pass urine
  • small bladder capacity, so you need to go to the toilet frequently
  • fatigue
  • loss of appetite
  • diarrhoea
  • soreness around the anus.

Less commonly, radiotherapy may permanently affect the bowel or bladder. More frequent and looser bowel motions may occur. You may also have bladder irritation and blood in the urine.

More on radiotherapy

Palliative treatment

If the bladder cancer spreads or returns after treatment, your doctor will discuss palliative treatment for symptoms caused by the cancer, such as pain.

Palliative treatment aims to manage symptoms without trying to cure the disease. It can be used at any stage of advanced cancer to improve quality of life. It is not just for people who are about to die and does not mean giving up hope. Rather, it is about living for as long as possible in the most satisfying way you can.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. The treatment may include radiotherapy, chemotherapy, targeted therapies or other types of medicine.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, practical and spiritual needs. The team also provides support to families and carers. For more information, see palliative care and living with advanced cancer.

Key points

  • Bladder cancer that has invaded muscle is usually treated with surgery, which may be used with other treatments such as chemotherapy and radiotherapy.
  • The most common surgery for bladder cancer is a radical cystectomy. The whole bladder and nearby lymph nodes are removed (sometimes with other organs).
  • A partial cystectomy (which removes only the tumour) is a less common operation.
  • You may have open surgery (one large cut) or keyhole surgery (several small cuts).
  • If the whole bladder has been removed, you will need reconstructive surgery to store urine in another way. This is known as a urinary diversion.
  • Surgery is also the main form of treatment for urothelial cancer of the ureter or kidney. The operation to remove a kidney, ureter and part of the bladder is known as a nephroureterectomy.
  • In systemic chemotherapy, drugs are injected into your body to treat the cancer. This treatment is usually given in a course over a few days, and the course may be repeated every few weeks for several months.
  • Radiotherapy uses high- energy x-rays to kill the cancer cells or injure them. The treatment is usually given Monday to Friday over several weeks.
  • Palliative treatment may be used to treat the symptoms of advanced bladder cancer and improve quality of life. It is part of palliative care.

Reviewed by: A/Prof Manish Patel, Urological Cancer Surgeon, Westmead Private and Macquarie University Hospitals and University of Sydney, NSW; Gregory Bock, Urology Cancer Nurse Coordinator, WA Cancer and Palliative Care Network, Department of Health, WA; Leslie Leckie, Consumer; A/Prof Declan Murphy, Urologist, Chair of Uro-Oncology and Director of Robotic Surgery, Peter MacCallum Cancer Centre, VIC; Jan Priaulx, 13 11 20 Consultant, Cancer Council NSW.
Updated: 01 Feb, 2016