Bladder cancer


Treatment for muscle invasive bladder cancer

When bladder cancer has invaded the muscle, the most common treatment is surgery to remove the entire bladder. Other treatments, such as chemotherapy, may be given before or after surgery. Some bladder cancers may be treated with a combination of chemotherapy and radiation therapy only.

Surgery

Most people with muscle-invasive disease or cancer that has invaded the lamina propria and has not responded to BCG, have surgery to remove the bladder (cystectomy).

Removing the whole bladder (radical cystectomy)

This 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 part of the vagina are often removed.

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.

What to expect after surgery

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. It's common to have pain after the surgery and you may need pain relief for a few days.

How the surgery is done

Different surgical methods may be used for muscle-invasive bladder cancer.

Open surgery makes one long cut (incision). Keyhole surgery, also known as minimally invasive or laparoscopic surgery, uses several smaller cuts, sometimes with help from a robotic system.

Recovery is often faster and the hospital stay is shorter with keyhole surgery, but open surgery is recommended in some situations.

Talk to your surgeon about the pros and cons† of each option. If robotic-assisted surgery is suggested, check what fees are involved. Unless you are treated as a public patient in a hospital or treatment centre that offers this at no extra cost, robotic surgery can be an expensive operation.

Side effects of cystectomy

Effects on urination

If you have 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, you will need to collect and store urine in another way. This is called urinary diversion – for more information, see living with a bladder reconstruction.

Effects on sexuality

In men, the nerves needed for 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 your fertility and how you feel about your sex life.

Urothelial carcinoma of the kidney or ureter

Urothelial carcinoma is the most common form of bladder cancer, but occasionally it can occur in part of the kidney (renal pelvis), a ureter or urethra.

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 kidney or ureter needs to be removed and in some cases a laser can be used to remove the tumour endoscopically. You may have chemotherapy or immunotherapy 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 into 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 radiation therapy (sometimes called chemoradiation) if a person is reluctant to have surgery
  • to treat bladder cancer that has spread to other parts of the body.

Systemic chemotherapy is given as a course of drugs every 2–3 weeks for several months. Usually a combination of drugs works better than one drug alone. The drugs you are offered will depend on your age, fitness, kidney function and personal preference. Researchers are studying whether it's best to have chemotherapy before (neoadjuvant) or after (adjuvant) surgery. Your surgeon will probably discuss the best approach for you at an MDT meeting.

Side effects of systemic chemotherapy

Common side effects may include fatigue, nausea and vomiting, mouth sores, taste changes, itchy skin, hair loss, and tingling or numbness of fingers or toes. 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 immediately to the emergency department at your nearest hospital.

Ask your medical team for more information about coping with side effects. You can also see Understanding Chemotherapy and Understanding Radiation Therapy or call Cancer Council 13 11 20.

Radiation therapy

Radiation therapy, also known as radiotherapy, uses radiation such as x-rays or electron beams to damage or kill cancer cells. It may be used instead of surgery to treat muscle-invasive bladder cancer. On its own, radiation therapy may not cure the cancer. Sometimes, chemotherapy is given with radiation therapy to make the radiation work better. This is called chemoradiation, and has been shown to work as well as surgery.

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

People who have chemoradiation will need to have regular cystoscopies after treatment.

Side effects of radiation therapy

Radiation therapy 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 and soreness around the anus.

Less commonly, radiation therapy may permanently affect the bowel or bladder. More frequent and looser bowel motions may occur. You may also have damage to the lining of the bladder. This is known as radiation cystitis, which can cause blood in the urine.

Immunotherapy

Immunotherapy uses the body's own immune system to fight cancer. BCG is a type of immunotherapy treatment used to treat non-muscle-invasive bladder cancer.

A new group of immunotherapy drugs work by blocking barriers called checkpoints. These barriers are created by cancer cells to protect against attack from the immune system. The checkpoint inhibitors help make the cancer cells visible to the body's own immune system. Once the barrier is removed, the immune system can recognise and destroy the cancer.

Several of these checkpoint immunotherapy drugs are already approved for the treatment of other cancers like melanoma and lung cancer. They may soon be reimbursed for bladder cancer. Clinical trials are testing whether having checkpoint immunotherapy with chemotherapy and radiation therapy will benefit people with bladder cancer that has spread into the bladder wall. To find out more, see Understanding Immunotherapy or call Cancer Council 13 11 20.

Side effects of immunotherapy

Like all treatments, checkpoint immunotherapy can cause side effects. Because checkpoint immunotherapy acts on the immune system, it can cause inflammation in any part of the body. This can lead to a variety of side effects such as skin rash, diarrhoea and breathing problems.

Palliative treatment

Palliative treatment helps to improve people's quality of life by managing symptoms of cancer without trying to cure the disease, and is best thought of as supportive care.

Many people think that palliative treatment is only for people at the end of their life; however, it can help people at any stage of advanced bladder cancer. 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. Treatment may include radiation therapy, chemotherapy or targeted therapy.

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 Understanding Palliative Care and Living with Advanced Cancer or call Cancer Council 13 11 20.

Key points

  • Bladder cancer that has invaded muscle is usually treated with surgery. You may also have chemotherapy and radiation therapy.
  • The most common surgery is radical cystectomy, which removes the whole bladder and nearby lymph nodes. Other nearby organs may also be removed.
  • Removing only the bladder tumour (partial cystectomy) is a less common operation.
  • You may have open surgery (one large cut) or keyhole surgery (several small cuts).
  • After a radical cystectomy, you will need surgery to store urine in another way. This is known as urinary diversion.
  • Surgery is also the main form of treatment for urothelial carcinoma of the kidney or ureter. 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 repeated every few weeks for a number of months.
  • Radiation therapy uses high energy x-rays to kill the cancer cells or injure them. It is often combined with chemotherapy. The treatment is usually given Monday to Friday over several weeks.
  • Immunotherapy stimulates the body's immune system to fight cancer. Several drugs are being studied in clinical trials and may be available soon.
  • Palliative treatment may be used to treat the symptoms of advanced bladder cancer and improve quality of life.

Expert content reviewers:

Phil Dundee, Urological Surgeon, Epworth Hospital, VIC; David Connah, Consumer; Dr Elizabeth Hovey, Senior Staff Specialist, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, and Conjoint Senior Lecturer, University of New South Wales, NSW; Colleen McDonald, Clinical Nurse Consultant Urology, Westmead Hospital, NSW; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council Western Australia, WA; Kerry Santoro, Urology Nurse Consultant, Repatriation General Hospital, SA.

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