Treatment for bladder cancer

The treatment options for bladder cancer largely depend on how advanced the cancer is.

Treatments usually differbetween early stage, non-muscle-invasive bladder cancer and more advanced muscle-invasive bladder cancer.

Multidisciplinary teams (MDTs)

All hospitals use MDTs to treat bladder cancer. These are teams of specialists that work together to make decisions about the best way to proceed with your treatment.

Members of your MDT may include:

• a urologist a surgeon specialising in treating conditions affecting the urinary tract
• a clinical oncologist a specialist in chemotherapy and radiotherapy
• a pathologista specialist in diseased tissue
• a radiologist a specialist in detecting disease using imaging techniques

You should be given the contact details for a clinical nurse specialist, who will be in contact with all members of your MDT.They'll be able to answer questions and support you throughout your treatment.

Deciding what treatment is best for you can be difficult. Your MDT will make recommendations, but remember that the final decision is yours.

Before discussing your treatment options, you may find it useful to write a list of questions to ask your MDT.

Non-muscle-invasive bladder cancer

If you've been diagnosed with non-muscle-invasive bladder cancer (stages CIS, Ta and T1), your recommended treatment plan depends on the risk of the cancer returning or spreading beyond the lining of your bladder.

This risk is calculated using a series of factors, including:

• the number of tumours present in your bladder
• whether the tumours are larger than 3cm (one inch) in diameter
• whether you've had bladder cancer before
• the grade of the cancer cells

These treatments are discussed in more detail below.

Low-risk

Low-risk non-muscle-invasive bladder cancer is treated with transurethral resection of a bladder tumour (TURBT). This procedure may be performed during your first cystoscopy, when tissue samples are taken for testing (see diagnosing bladder cancer ).

TURBT is carried out under general anaesthetic . The surgeon uses an instrument called a cystoscope to locate the visible tumours and cut them away from the lining of the bladder. The wounds are sealed (cauterised) using a mild electric current, and you may be given a Urinary catheterisation to drain any blood or debris from your bladder over the next few days.

After surgery,youshould be given asingle dose of chemotherapy , directly into your bladder,using a catheter. The solution is kept in your bladder for around an hour before being drained away.

Most people are able to leave hospital less than 48 hours after having TURBT and are able to resume normal physical activity within two weeks.

You should be offered follow-up appointments at three months and nine months to check your bladder, using a cystoscopy . If your cancer returns after six months, and is small,you may be offered a treatment called fulguration. This involves using an electric current to destroy the cancer cells.

Intermediate-risk

People with intermediate-risk non-muscle-invasive bladder cancer should be offered a course of at least six doses of chemotherapy. The liquid is placed directly into your bladder,using a catheter, and kept there for around an hour before being drained away.

You should be offered follow-up appointments at three months, nine months, 18 months, then once every year.Atthese appointments, your bladder will be checked using a cystoscopy.If your cancer returns within five years, you'll be referred back to a specialist urology team.

Some residue of the chemotherapy medication may be left in your urine after treatment, which could severely irritate your skin. It helpsif you urinate while sitting down and that you're careful not to splash yourself or the toilet seat. After passing urine, wash the skin around your genitals with soap and water.

If you're sexually active, it's important to use a barrier method of contraception , such as a condom. This isbecause the medication may be present in your semen or vaginal fluids, which can cause irritation.

You also shouldn't try to get pregnant or father a child while having chemotherapy for bladder cancer, as the medication can increase the risk of having a child with birth defects.

High-risk

People with high-risk non-muscle-invasive bladder cancer should be offered a second TURBT operation, within six weeks of the initial investigation(see diagnosing bladder cancer ). A CT scan or an MRI scan may also be required.

Your urologist and clinical nurse specialistwill discussyour treatment options with you, which will either be:

• a course of Bacillus Calmette-Gurin (BCG) treatment using a variant of the BCG vaccine
• an operation to remove your bladder (cystectomy)

The BCG vaccine is passed into your bladder through a catheter and left for two hours before being drained away. Most people require weekly treatments over a six-week period. Common side effects ofBCG include:

• a frequent need to urinate
• pain when urinating
• blood in your urine (haematuria)
• flu-like symptoms, such as tiredness, fever and aching
• urinary tract infections

IfBCGtreatment doesn't work, or the side effects are too strong, you'll be referred back to a specialist urology team.

You should be offered follow-up appointments every three months for the first two years, then every six months for the next two years, then once a year.Atthese appointments, your bladder will be checked using a cystoscopy .

If you decide to have a cystectomy, your surgeon willneed tocreate an alternative way for urine to leave your body (urinary diversion). Your clinical nurse specialist can discuss your options for the procedure and how the urinary diversion will be created.

Read about the complications of bladder cancer surgery for more information about urinary diversion and sexual problems after surgery.

After having a cystectomy,you should be offered follow-up appointments including a CT scan at six and 12 months, andblood tests once a year. Men require an appointment to check their urethra once a year for five years.

Muscle-invasive bladder cancer

The recommended treatment plan for muscle-invasive bladder cancer depends on how far the cancer has spread. With T2 andT3 bladder cancer, treatment aims to cure the condition if possible, or at least control it for a long time.

Your urologist, oncologist and clinical nurse specialistwill discussyour treatment options with you, which will either be:

• an operation to remove your bladder (cystectomy) see above
• radiotherapy with a radiosensitiser

Your oncologistshould also discuss the possibility of having chemotherapy before eitherof these treatments (neoadjuvant therapy), if it's suitable for you.

Radiotherapy with a radiosensitiser

Radiotherapy is given by a machine that beams the radiation at the bladder (external radiotherapy). Sessions are usually given on a daily basis for five days a week over the course of four to seven weeks. Each session lasts for about 10 to 15 minutes.

A radiosensitisershould also be given alongside radiotherapy for muscle-invasive bladder cancer. This is a medicine which affects the cells of a tumour, to enhance the effect of radiotherapy. It has a much smaller effect on normal tissue.

As well as destroying cancerous cells, radiotherapy can also damage healthy cells, which means it can cause a number of side effects. These include:

• diarrhoea
• inflammation of the bladder (cystitis)
• tightening of the vagina (in women), which can make having sex painful
• erectile dysfunction (in men)
• loss of pubic hair
• infertility
• tiredness
• difficulty passing urine

Most of these side effects should pass a few weeks after your treatment finishes, although there's a chance they'll be permanent.

Having radiation directed at your pelvis usually means you'll be infertile for the rest of your life.However, most people treated for bladder cancer are too old to have children, so this isn't usually a problem.

After having radiotherapy for bladder cancer,you should be offered follow-up appointmentsevery three months for the first two years, then every six months for the nexttwo years, and every year after that.Atthese appointments, your bladder will be checked using a cystoscopy .

You may also be offered CT scans of your abdomen, pelvis and chest after six months, one year and two years. A CT scan of your urinary tract may be offered every year for five years.

Surgery or radiotherapy?

Your MDT may recommend a specific treatmentbecause ofyour individual circumstances.

For example, someone with a small bladder ormany existing urinary symptoms is better suited to surgery. Someone who has a single bladder tumour with normal bladder function is better suited for treatments that preserve the bladder.

However, your input is also important, so you should discuss which treatment is best for you with your MDT.

There are pros and cons of both surgery and radiotherapy.

The pros of having a radical cystectomy include:

• treatment is carried out in one go
• you won't need regular cystoscopies after treatment, although other less invasive testsmay be needed

The cons of having a radical cystectomy include:

• it can take up to three months to fully recover
• a risk of general surgical complications, such as pain, infection and bleeding
• a risk of complications from the use ofgeneral anaesthetic
• an alternative way of passing urine out of your body needs to be created, which may involve an external bag
• a high risk of erectile dysfunction in men (estimated at around 90%)as a result of nerve damage
• after surgery, some women may find sex uncomfortable, as their vagina may be smaller
• a small chance of a fatal complication, such as a heart attack , stroke or deep vein thrombosis (DVT)

The pros of having radiotherapy include:

• there's no need to have surgery, which is often an important consideration for people in poor health
• your bladder function may not be affected, as your bladder isn't removed
• there's less chance of causing erectile dysfunction (around 30%)

The cons of having radiotherapy include:

• you'll require regular sessions of radiotherapy for four to seven weeks
• short-term side effects are common,such as diarrhoea, tiredness and inflammation of the bladder (cystitis)
• a small chanceof permanently damaging the bladder, which could lead to problems urinating
• women may experience a narrowed vagina, making sex difficult and uncomfortable

Chemotherapy

In some cases, chemotherapy may be used during treatment for muscle-invasive bladder cancer. Instead of medication being put directly into your bladder, it's put into a vein in your arm. This is called intravenous chemotherapy and can be used:

• before radiotherapy and surgery to shrink the size of any tumours
• in combination with radiotherapy before surgery (chemoradiation)
• to slow the spread of incurable advanced bladder cancer (palliative chemotherapy)

There isn't enough evidence to say whether chemotherapy is an effective treatment when it's given after surgery to prevent the cancer returning. It's usually only used this way as part of a clinical trial .See clinical trials for bladder cancer for more information.

Chemotherapy is usually given over a few consecutive days at first. You'll then have a few weeks off to allow your body to recover before the treatment begins again. This cycle will be repeated for a few months.

As the chemotherapy medication is being injected into your blood, you'll experience a wider range of side effects than if you were having chemotherapy directly into the bladder. These side effects should stop after the treatment has finished.

Chemotherapy weakens your immune system, making you more vulnerable to infection. It's important to report any symptoms of a potential infection, such as a high temperature, persistent cough or reddening of the skin, to your MDT. Avoid close contact with people who are known to have an infection.

Otherside effects of chemotherapy can include:

• nausea
• vomiting
• hair loss
• lack of appetite
• tiredness

Locally advanced or metastatic bladder cancer

The recommended treatment plan forlocally advanced or metastatic bladder cancerdepends on how far the cancer has spread. Your oncologist should discuss your treatment options with you, which may include:

• a course of chemotherapy
• treatments to relieve cancer symptoms

Chemotherapy

If you receive a course of chemotherapy, you'll be given a combination of drugs to help relieve the side effects of treatment. Treatment may be stopped if chemotherapy isn't helping, or a second course may be offered.

Relieving cancer symptoms

You may be offered treatment to relieve any cancer symptoms. This may include:

• radiotherapy to treat painful urination, blood in urine, frequently needing to urinate or pain in your pelvic area
• treatment to drain your kidneys, if they become blocked and cause lower back pain

Palliative care

If you cancer is at an advanced stage and can't be cured, your MDT should discuss how the cancer will progress and which treatments are available to ease the symptoms.

You can be referred to a palliative care team, who can provide support and practical help, including pain relief.

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