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  • Treatment for bladder cancer

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    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.

    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.

    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.

    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.

    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 38o 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.

    For more information about immunotherapy, call Cancer Council 13 11 20 or you can download the fact sheet Understanding Immunotherapy.

    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.

    For more information about chemotherapy, call Cancer Council 13 11 20 or you can download the booklet Understanding Chemotherapy.

    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.

    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.

    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.

    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.  

    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.

    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.

    For more information about chemotherapy, call Cancer Council 13 11 20 or you can download the booklet Understanding Chemotherapy.

    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.

    For more information about radiotherapy, call Cancer Council 13 11 20 or you can download the booklet Understanding Radiation Therapy.

    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.

    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.

    For more information about immunotherapy, call Cancer Council 13 11 20 or you can download the fact sheet Understanding Immunotherapy.

    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 about paliative care, call Cancer Council 13 11 20 or you can download the booklet Understanding Palliative Care.

    This website page was last reviewed and updated September 2019

    Information reviewed by: 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. We also thank the health professionals, consumers and editorial teams who have worked on previous editions of this title.

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