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Treatment for bladder cancer
Non-muscle-invasive bladder cancer treatment
If cancer cells are found only in the inner layers of the bladder (non-muscle-invasive bladder cancer), the main treatment is surgery to remove the cancer. Surgery may be used on its own or combined with intravesical chemotherapy and intravesical immunotherapy.
After treatment, your doctor will follow up with you regularly.
Most people with non-muscle-invasive bladder cancer need to have an operation called transurethral resection of bladder tumour (TURBT). This is done during a rigid cystoscopy under a general anaesthetic. It takes 15–40 minutes, and does not involve any external cuts to the body.
A thin hollow tube with a light and 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 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 procedure to make sure that all cancer cells have been removed. If the cancer comes back after initial treatment, your surgeon may do another TURBT or might suggest removing the bladder in an operation known as a cystectomy.
What to expect after a TURBT
Most people who have a TURBT need to stay in hospital for 1–2 days. Your body needs time to heal after the surgery.
Contact your medical team promptly if you: feel cold, shivery, hot or sweaty; have burning or pain when urinating; need to urinate often and urgently; pass blood clots; or have difficulty passing urine.
Having a catheter
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.
Flushing the bladder
It is important to keep drinking lots of water to flush the bladder and keep the urine clear.
When you go home, avoid any heavy lifting, vigorous exercise or sexual activity for 3–4 weeks.
Side effects may include blood in the urine, problems storing urine, and bladder infections. It is normal to see some blood in your urine for up to two weeks. Your doctor may prescribe antibiotics to prevent infection.
Surveillance after surgery
Cancer can come back even after a TURBT has removed it from the bladder. You will need to have regular follow-up cystoscopies to help find any new tumours in the bladder as early as possible. This approach is known as surveillance cystoscopy.
How often you need to have a cystoscopy will depend on the stage and grade of the cancer and how long since it was diagnosed. For more information about follow-up appointments after surgery ask your surgeon.
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 chemotherapy drugs are usually given as tablets or injected into a vein, in intravesical chemotherapy the drugs are put directly into the bladder using a catheter, which is a thin, flexible tube inserted through the urethra.
Intravesical chemotherapy is used mainly for low- to medium-risk non-muscle-invasive bladder cancer. It helps prevent the cancer coming back (recurrence). This method can’t reach cancer cells outside the bladder lining or in 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 chemotherapy solution is left in the bladder for 60 minutes and then drained out through a catheter.
People with a medium risk of recurrence may have instillations once a week for six weeks. The chemotherapy solution 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 solution washes over the entire bladder.
While you are having a course of 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 of cystitis include wanting to pass urine more often or a burning feeling when urinating. Drinking plenty of fluids 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 is treatment that uses 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 high-risk non-muscle-invasive bladder cancer. 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. This is usually done as a day procedure in hospital, and each treatment session takes up to two hours.
Your treatment team will outline some safety measures to follow afterwards at home. This is because BCG is a vaccine that contains live bacteria, which can harm healthy people.
BCG safety at home
- For the first six hours after BCG treatment, sit down on the toilet when urinating to avoid splashing. Pour 2 cups of household bleach (or a sachet of sodium hydrochlorite if provided by your treatment team) into the toilet bowl. Wait 15 minutes before flushing and wipe the toilet seat with bleach.
- If you are wearing incontinence pads, 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.
- For a few days after treatment, wash your hands extra well after going to the toilet, and wash or shower if your skin comes in contact with urine.
- Speak to your doctor or nurse if you have any questions.
Ongoing BCG treatment
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. Maintenance treatment can last for 1–3 years, but treatment sessions become much less frequent (e.g. once a month). Ask your doctor for further details.
Side effects of BCG
Common side effects of BCG include needing to urinate more often; burning or pain when urinating; blood in the urine; a mild fever; and tiredness. These side effects usually last a couple of days after each BCG treatment session.
Less often, the BCG may spread through the body and can affect any organ. 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, tiredness, or yellow skin (jaundice), contact your nurse or doctor immediately. A BCG infection can be treated with medicines. Very rarely, BCG can cause infections in the lungs or other organs months or years after treatment. If you are diagnosed with an infection in the future, it is important to tell the doctor that you had BCG treatment.
Let your doctor know of any other medicines or complementary therapies you are using, 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.
Muscle-invasive bladder cancer treatment
When bladder cancer has invaded the muscle layer, the most common treatment is surgery to remove the whole bladder. Other treatments, such as chemotherapy and radiation therapy, may be given before or after surgery. A small number of muscle-invasive bladder cancers may be treated with a simpler surgery, followed by chemotherapy combined with radiation therapy. This is known as trimodal therapy.
Urothelial carcinoma of the ureter or kidney
While urothelial carcinoma is the most common form of bladder cancer, it occasionally occurs in a ureter or part of the kidney (renal pelvis).
Much of this information about bladder cancer will be relevant if you have been diagnosed with urothelial cancer of the ureter or kidney. 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. This uses a ureteroscope, a thin instrument with a light, to examine the ureters and kidneys.
The most common treatment is surgery to remove the affected 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 sent through a ureteroscope to remove the tumour. You may have chemotherapy or immunotherapy after the surgery.
Most people with muscle-invasive disease have surgery to remove the bladder (cystectomy). This may also be recommended for cancer in the lamina propria that has not responded to BCG.
The surgeon usually needs to remove the whole bladder. This is called a radical cystectomy.
Less commonly, it may be possible to do a partial cystectomy. This removes only the tumour and a border of healthy tissue. The bladder will be smaller, so you may need to pass urine more often.
How the surgery is done
Surgery to remove the bladder (cystectomy) is a major and complicated operation. It is important to have this surgery in a specialised centre with a surgeon who does a lot of cystectomies.
Different surgical methods may be used for removing the bladder. 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 may be faster and the hospital stay may be shorter with keyhole surgery, but open surgery is recommended in some situations. In general, having a very experienced surgeon is more important than the type of surgery.
Talk to your surgeon about the pros and cons of each approach, and check what you’ll have to pay. Unless you are treated as a public patient in a hospital or treatment centre that offers this surgery at no extra cost, cystectomy can be an expensive operation.
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 fluids from the operation area. It’s common to have pain after the surgery, so you may need pain relief for a few days.
A cystectomy will affect how you store urine and urinate, and it can also affect sexuality and fertility in various ways.
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.
In most cases, systemic chemotherapy is given before surgery to shrink the cancer, make it easier to remove and reduce the risk of the cancer coming back. This is known as neoadjuvant chemotherapy. Occasionally, chemotherapy may be given after surgery (adjuvant chemotherapy) if there is a high risk of the cancer coming back.
You will see a medical oncologist to plan your chemotherapy treatment. In most cases, the chemotherapy will be given as a course of drugs every 2–3 weeks over a few 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.
If a person is reluctant or unable to have surgery to remove the bladder, systemic chemotherapy can sometimes be combined with radiation therapy (chemoradiation) as part of trimodal therapy. Systemic chemotherapy may also be used for bladder cancer that has spread to other parts of the body.
Side effects of systemic chemotherapy
Common side effects may include fatigue, nausea and vomiting, constipation, mouth sores, taste changes, itchy skin, hair loss, and tingling or numbness of fingers or toes. Side effects are usually temporary, but can be long-term or permanent. Talk to your doctor about whether medicines may ease these side effects.
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.
Radiation therapy, also called radiotherapy, uses a controlled dose of radiation to kill or damage cancer cells. The radiation is usually in the form of x-ray beams. On its own, radiation therapy can help to control bladder cancer. In this case, you may have a single session, or up to 20 sessions given Monday to Friday over four weeks. This approach may be recommended if you are too unwell for other treatments or if the cancer has spread to other parts of the body. Radiation therapy can sometimes be combined with other treatments with the aim of curing the cancer.
You will meet with the radiation oncology team to plan your treatment. During a radiation therapy session, you will lie on an examination table, and a machine will direct the radiation towards your bladder. The treatment is painless and can’t be seen or felt.
Side effects of radiation therapy
Radiation therapy for bladder cancer can cause temporary side effects, including needing to urinate more often and more urgently, burning when you pass urine, fatigue, loss of appetite, diarrhoea and soreness around the anus. Symptoms tend to build up during treatment and usually start improving over a few weeks after treatment ends.
Less commonly, radiation therapy may permanently affect the bowel or bladder. Bowel motions may be more frequent and looser, and damage to the lining of the bladder (radiation cystitis) can cause blood in the urine. Radiation therapy may also cause poor erections and make ejaculation uncomfortable for some months after treatment.
For some people with muscle-invasive tumours, trimodal therapy may be used instead of cystectomy. This involves three types of treatment: a shorter surgery to remove the bladder tumour followed by a combination of chemotherapy and radiation therapy (chemoradiation). The chemotherapy makes the cancer cells more sensitive to radiation.
If you have chemoradiation, you will usually receive chemotherapy once a week a few hours before the radiation therapy appointment. The radiation therapy is usually given from Monday to Friday for up to seven weeks.
During and after chemoradiation, you may experience side effects from both the chemotherapy and the radiation therapy. Talk to your treatment team about ways to manage the side effects of chemoradiation.
Trimodal therapy has the advantage of not removing the bladder, so you can still urinate in the usual way. You will need to have regular cystoscopies after treatment to check that the cancer has not come back. Some people who have had trimodal therapy for muscle-invasive bladder cancer will later need their bladder removed because the cancer has come back.
Some studies show that trimodal therapy works as well as cystectomy, while others show that cystectomy has better survival rates. Talk to your medical team about whether trimodal therapy may be an option in your situation
Advanced bladder cancer treatment
If bladder cancer has spread to other parts of the body, it is known as advanced or metastatic bladder cancer. You may be offered one or a combination of the following treatments to help control the cancer and ease symptoms.
Immunotherapy uses the body’s own immune system to fight cancer. BCG is a type of immunotherapy treatment that has been used for many years to treat non-muscle-invasive bladder cancer. A new group of immunotherapy drugs called checkpoint inhibitors work by helping the immune system to recognise and attack the cancer.
A checkpoint immunotherapy drug called pembrolizumab is now available in Australia for some people with urothelial cancer that has spread beyond the bladder. The drug is given directly into a vein through a drip, and the treatment may be repeated every 2–4 weeks for up to two years.
Other types of checkpoint immunotherapy drugs may become available soon. Clinical trials are testing whether combining newer checkpoint immunotherapy drugs with chemotherapy and radiation therapy will benefit people with bladder cancer.
Side effects of immunotherapy
Like all treatments, checkpoint inhibitors can cause side effects. Because these drugs act on the immune system, they can sometimes cause the immune system to attack healthy cells in any part of the body. This can lead to a variety of side effects such as skin rash, diarrhoea, breathing problems and temporary arthritis.
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 surgery to control the cancer.
Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, cultural, social and spiritual needs. The team also provides support to families and carers.
This information is reviewed by
This information was last reviewed in February 2020 by the following expert content reviewers: Prof Dickon Hayne, UWA Medical School, The University of Western Australia, and Head, Urology, South Metropolitan Health Service, WA; BEAT Bladder Cancer Australia; Dr Anne Capp, Senior Staff Specialist, Radiation Oncology, Calvary Mater Newcastle, NSW; Marc Diocera, Genitourinary Nurse Consultant, Peter MacCallum Cancer Centre, VIC; Dr Peter Heathcote, Senior Urologist, Princess Alexandra Hospital, and Adjunct Professor, Australian Prostate Cancer Research Centre, QLD; Melissa Le Mesurier, Consumer; Dr James Lynam, Medical Oncologist Staff Specialist, Calvary Mater Newcastle and The University of Newcastle, NSW; John McDonald, Consumer; Michael Twycross, Consumer; Rosemary Watson, 13 11 20 Consultant, Cancer Council Victoria.