Treatment for non-muscle-invasive bladder cancer


The main treatments for when the cancer cells are found only in the bladder's inner lining (non-muscle-invasive bladder cancer) are surgery, immunotherapy and intravesical chemotherapy. Surgery, on its own or combined with other treatments, is used in most cases.

After treatment, your doctor will follow up with you regularly. See below for information about these appointments.

Surgery

Most people with non-muscle-invasive bladder cancer have an operation called transurethral resection of bladder tumour (TURBT). This 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 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 after the first to make sure that all microscopic cancer has been removed. If the cancer comes back after standard treatment, your surgeon may do another TURBT or might suggest removing the bladder in an operation known as a cystectomy.

Surveillance after surgery

Bladder cancer can come back even after it has been successfully removed from the bladder. You will need to have regular follow-up cystoscopies to help find any new tumours as early as possible, whether you have further symptoms or not. This is called surveillance cystoscopy.

How often you need to have a cystoscopy will depend on the grade and stage of the cancer and how long since it was diagnosed.

For more information about follow-up appointments after surgery, ask your surgeon or see follow-up care.

What to expect after surgery

Recovery time

Most people who have TURBT surgery need to stay in hospital for 1–2 days. It is important to give your body time to heal after the surgery. When you go home, avoid any heavy lifting, strenuous exercise or sexual activity for 3–4 weeks.

Drips and tubes

You may have a thin tube (catheter) in your bladder to drain 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 your urine looks clear, 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. It is important to keep drinking lots of water to flush the bladder and keep the urine clear.

Side effects of TURBT surgery

The most common side effects after a TURBT are blood in the urine, issues storing urine, and bladder infections. It is normal to see blood in your urine for up to two weeks after the procedure.

Signs of problems with storing urine or bladder infection include: feeling cold, shivery, hot or sweaty; burning or pain when urinating; needing to urinate often and urgently; passing blood clots; or difficulty passing urine. To prevent infection, your doctor may prescribe a course of antibiotics.

Immunotherapy

Immunotherapy uses substances that encourage the body's own natural defences (immune system) to fight disease. Bacillus Calmette-Guérin (BCG) is a vaccine that was originally used to treat tuberculosis. 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 many non-muscle-invasive bladder cancers, including carcinoma in situ, high-grade tumours, and those that have grown into the lamina propria.

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

For most people, the initial course of weekly BCG treatments is followed by what is known as maintenance BCG. Maintenance treatment with BCG reduces the risk of the disease coming back or spreading. This treatment can last 1–3 years, but the treatments are given much less frequently, often monthly. Ask your doctor for further details.

Using BCG safely 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.

  • For the first six hours after BCG treatment, sit down on the toilet when urinating to avoid splashing.
  • Pour a small amount of household bleach into the toilet bowl and leave for 15 minutes before flushing and wiping the toilet seat.
  • Wash your hands thoroughly after going to the toilet.
  • If you are wearing incontinence pads in case of leakage, take care when disposing of them. Pour bleach on the used pad, allow it to soak in, then place the pad in a plastic bag, seal the bag and put it in your rubbish bin. You may be able to take it back to the hospital or treatment centre for disposal in a biohazard bin.
  • If any clothing is splashed with urine, wash separately in bleach and warm water.
  • Wash or shower if your skin comes in contact with urine for the first few days after treatment.
  • Speak to your doctor or nurse if you have questions about these safety measures.

Side effects of BCG treatment

Common side effects of BCG include needing to urinate more often, burning or pain when passing urine, and blood in your urine, as well as a mild fever and tiredness for a couple of days. Let your doctor know of any other medicines 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.

If you develop flu-like symptoms, such as fever over 38°C that lasts longer than 72 hours, pain in your joints, a cough, a skin rash, or severe tiredness, or your skin becomes yellow (jaundice), it is important to contact your nurse or doctor immediately. This may mean a BCG infection has spread throughout the body. However, this is an uncommon reaction.

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. Although the drugs are usually given as tablets or injected into a vein (systemic chemotherapy), in intravesical chemotherapy the drugs are put directly into the bladder using a flexible tube called a catheter, which has been inserted through the urethra.

Intravesical chemotherapy is used only for non-muscle-invasive bladder cancer. It helps keep the cancer from coming back (recurrence). This form of chemotherapy can't reach cancer cells outside of the bladder lining or other parts of the body, so it's not suitable for muscle-invasive bladder cancer. Each treatment is called an instillation.

People with a low risk of recurrence usually have one instillation at the time of TURBT surgery. The solution is left in the bladder for 60 minutes and then drained out through a catheter.

People with a moderate risk of recurrence usually have weekly instillations for six weeks. Once the bladder is filled with the chemotherapy, it is left in the bladder for up to two hours and then drained through the catheter. You may be asked to change position every 15 minutes so the chemotherapy washes over the entire bladder.

During the period you are having intravesical chemotherapy, 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 inflammation (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.

Key points

  • The main treatments for non-muscle-invasive bladder cancer include surgery, BCG (immunotherapy) and intravesical chemotherapy. You may have surgery alone or a combination of these treatments.
  • Most people have a transurethral resection of bladder tumour (TURBT) operation. This is done during a cystoscopy under general anaesthetic.
  • 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.
  • 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 at home.
  • 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 inflammation (cystitis).

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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