Treatment for non-muscle-invasive bladder cancer

Monday 1 February, 2016

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The main treatments for non-muscle-invasive bladder cancer are surgery, intravesical chemotherapy and immunotherapy. Surgery, alone or combined with other treatments, is used in most cases. After treatment, your doctor will follow up with you regularly.

Surgery

Most people with non-muscle-invasive bladder cancer have a type of surgery called transurethral resection of bladder tumour (TURBT). The TURBT is done during a cystoscopy under a general anaesthetic. It takes 15–40 minutes, and does not involve any external cuts to the body.

A slender hollow tube with a light and a camera, known as a cystoscope, is passed through the urethra and into the bladder. The surgeon may use a wire loop on the cystoscope to remove the tumour through the urethra. Other methods for destroying the cancer cells include burning the base of the tumour with the cystoscope (fulguration), or using a high-energy laser.

If the cancer has reached the lamina propria or is high grade, you may need a second TURBT 2–6 weeks later. This is to ensure that all microscopic cancer has been removed.

If the cancer comes back, your surgeon may do another TURBT or might suggest removing the bladder in an operation known as a cystectomy.
Side effects of TURBT surgery

Most people who have TURBT surgery need to stay in hospital for 1–2 days. After the operation, you may have a thin tube (catheter) in your bladder, which drains your urine into a bag. The catheter may be connected to a system that washes the blood and blood clots out of your bladder. This is known as bladder irrigation.

When there is no longer a risk of clots, the catheter will be removed and you will be able to go home. If the tumour is small, there may be no need for a catheter, and you may be discharged from hospital on the same day.

The most common side effects after a TURBT are blood in the urine and bladder infection. It is normal to see blood in your urine for up to two weeks after the procedure. To prevent infection, your doctor may prescribe a course of antibiotics. Signs of a bladder infection include chills or fever, burning or pain when urinating, passing blood clots or difficulty passing urine.

It is important to give your body time to heal after the surgery, and your doctor will advise you about gradually returning to your usual activities. Avoid any heavy lifting, strenuous exercise or sexual activity for 3–4 weeks.

Some people are given intravesical chemotherapy (see below) immediately after or within 24 hours of surgery.

Intravesical 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. The drugs are usually given as tablets or injected into a vein (systemic chemotherapy). In intravesical chemotherapy, however, the drugs are put directly into the bladder using a flexible tube called a catheter.

Intravesical chemotherapy is used only for non-muscle-invasive bladder cancer. This form of chemotherapy can’t reach cancer cells in surrounding tissues or other parts of the body, so it’s not suitable for muscle-invasive bladder cancer.

Each treatment is called an instillation. The chemotherapy treatment may be given as one instillation at the time of surgery, or as weekly instillations for six weeks. During this time, your doctor may advise you to use contraception.

Side effects of intravesical chemotherapy

Because intravesical chemotherapy puts the drugs directly into the bladder, it has fewer side effects than systemic chemotherapy, when the drugs reach the whole body.

The main side effect is bladder irritation (cystitis). Signs include wanting to pass urine more often or a burning feeling when urinating. Drinking plenty of fluids after treatment can help. If you develop a bladder infection, your doctor can prescribe antibiotics. In some people, intravesical chemotherapy may cause a rash on the hands or feet. Tell your doctor if this occurs.

Immunotherapy

Immunotherapy uses substances that encourage the body’s own natural defences (immune system) to fight disease. Bacillus Calmette-Guérin (BCG) is a vaccine originally developed to prevent tuberculosis, but it can also stimulate a person’s immune system to stop or delay bladder cancer coming back or becoming invasive.

The combination of BCG and TURBT is the most effective treatment for non-muscle-invasive bladder cancers, including carcinoma in situ and cancer that has grown into the lamina propria.

BCG is initially given once a week for six weeks, starting 2–4 weeks after TURBT surgery. It is put directly into the bladder through a catheter (instillation). You may be asked to change position every 15–20 minutes so the vaccine washes over the entire bladder. Each treatment session takes up to three hours.

For most people, the initial course of BCG treatments is followed by maintenance treatment. This long-term therapy can last 1–3 years, but the treatments are given much less frequently. Maintenance treatment reduces the risk of the disease progressing.

Let your doctor know of any other drugs or complementary therapies you are having, as they may interfere with how well the bladder cancer responds to BCG. For example, the drug warfarin (a blood thinner) is known to interact with BCG.

Side effects of BCG treatment

Common side effects of immunotherapy with BCG include blood in your urine, needing to urinate more often, and burning or pain when you pass urine, as well as a mild fever and tiredness for a couple of days. For people on maintenance therapy, these side effects may worsen with each treatment. If you develop flu-like symptoms, such as a high fever, pain in your joints, a cough, a skin rash or severe tiredness, it is important to contact your nurse or doctor immediately. This may mean a BCG infection has spread throughout the body. This is an uncommon reaction.

BCG and safety at home

After BCG treatment, your medical team will ask you to follow these safety measures. This is because BCG is a vaccine that contains live bacteria, which can harm healthy people.

  • Sit down on the toilet when urinating to avoid splashing.
  • For the first few hours after BCG treatment, disinfect the toilet with household bleach. Pour a small amount into the toilet bowl and leave for 15 minutes before flushing and wiping the toilet seat.
  • Wash your hands thoroughly.
  • You may be advised to wear incontinence pads in case of leakage. Place the used pad in a sealed plastic bag, then put it in your rubbish bin or take it back to the hospital or treatment centre for disposal in a biohazard bin.
  • If any clothing is splashed with urine, wash separately with bleach and warm water.
  • Speak to your doctor or nurse if you’re concerned about these precautions.

Key points

  • The main treatments for non-muscle-invasive bladder cancer include surgery, intravesical chemotherapy and BCG (immunotherapy). These treatments may be used alone or combined.
  • The doctor may be able to remove the cancer during a cystoscopy. However, most people have a transurethral resection of bladder tumour (TURBT) operation.
  • In a TURBT, a slender tube is passed through the urethra and into the bladder, and the doctor uses a wire loop to remove the cancer.
  • TURBT can be repeated if the cancer comes back.
  • Blood in the urine, pain and discomfort are common side effects after bladder surgery.
  • Chemotherapy drugs may be put directly into the bladder through a flexible tube called a catheter. This is called intravesical chemotherapy.
  • Each time the chemotherapy drugs are inserted, it is called an instillation.
  • The most common side effect of intravesical chemotherapy is bladder irritation (cystitis).
  • Immunotherapy uses a vaccine known as Bacillus Calmette-Guérin (BCG), which causes the body’s immune system to try to destroy the cancer. It is inserted directly into the bladder. BCG is usually given weekly for six weeks and followed up with long-term maintenance therapy.
  • BCG may cause flu-like side effects. Because it is a live vaccine, you will need to take some safety precautions.

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, NSW.
Updated: 01 Feb, 2016