The treatment options for bladder cancer largely depend on how advanced or aggressive the cancer is (its risk). When discussing treatment options with you, we would like for you to be as involved in planning your care as you wish. We encourage patients if they wish to, bring along a family member or friend with them to their appointments. We feel that it is very important to make time to listen and respond to any questions or concerns you may have, and to discuss any personal preferences or requirements that are important to you during your treatment. We will also provide you with contact details for your team as well as your cancer key-worker (dedicated clinical nurse specialist) who can provide ongoing support and information.
The treatments we are able to offer usually differ between non-muscle-invasive bladder cancer (cancer that is found superficially inside the bladder), more advanced muscle-invasive bladder (cancer that has spread to the muscle layer of the bladder) and metastatic bladder cancer (cancer that has spread beyond the bladder to other areas).
It is usual for a patient’s individual diagnosis and circumstances to be discussed as part of a multi-centre, multi-disciplinary team (MDT) review meeting. The meeting involves specialists from many different clinical disciplines who review each patient’s individual case and offer a consensus recommendation for treatment.
Non-muscle-invasive bladder cancer
If you have been diagnosed with non-muscle-invasive bladder cancer (superficial cancer) your recommended treatment plan will depend on the risk of the cancer returning or spreading beyond the lining of your bladder.
Your treatment plan will depend on how likely your cancer is to return. It may involve regular bladder surveillance (cystoscopy), removal of bladder tumours (TURBT), intravesical treatments (treatments of chemotherapy or BCG administered directly into the bladder) or a combination of these.
The team at UCLH are involved in discovering ways to improve bladder cancer treatment. For example we have been conducting studies to understand whether adding heat to chemotherapy can enhance its effect. The treatment is known as hyperthermia and there is mounting evidence to indicate that it is effective for some patients.
A visual inspection of the bladder is known as a cystoscopy. This involves a clinician passing a small fibre-optic camera (a cystoscope) along your water passage (urethra) and into the bladder. Cystoscopy is used to inspect the bladder to check for any new cancers growing on the bladder wall. Patients will usually have undergone a cystoscopy around the time that their bladder cancer was first discovered.
Cystoscopy can be performed as part of a regime of regular bladder surveillance either under local anaesthetic (flexible cystoscopy) or under general anaesthetic (rigid cystoscopy). The frequency of these bladder checks and the type of cystoscopy that is recommended will be discussed with you.
If you are undergoing a rigid cystoscopy under general anaesthetic, your surgical team may also recommend that a special liquid solution called Hexvix® is administered into your bladder via a small catheter (small tube passed into the bladder through the water passage) immediately before your procedure is carried out. The use of Hexvix® solution can help the surgeons to identify any smaller or less visible areas of bladder cancer. Written information about the use of Hexvix® can be provided on request.
During your rigid cystoscopy, small biopsies (samples of tissue) from the bladder wall may also be taken. If a bladder tumour is discovered during the procedure, the team will generally go on to perform a TURBT (see below) at the same time. The risks and benefits of these techniques will be discussed with you when you are asked to provide written consent for your procedure.
TURBT is carried out under general anaesthetic. The surgeon uses an instrument called a cystoscope to locate the visible tumours and shaves them away from the lining of the bladder. The wounds are then sealed (cauterised) using a mild electric current. The removed tumours are then sent to a laboratory for analysis (histopathology). TURBT may also be carried out if tumours are seen during routine bladder surveillance (see cystoscopy above).
Following TURBT (or if bladder biopsies are taken) you may experience blood in the urine (haematuria) and some bladder discomfort. When you wake up from your procedure you will find that a flexible tube called a catheter has been inserted into your bladder through your urethra and your urine is draining into a bag next to your bed. The catheter is used to drain away any blood and debris from your bladder, and sometimes if there is significant bleeding water can also be flushed into your bladder to help to control this. Once the bleeding has settled, the catheter will be removed before you leave hospital.
Most people are able to leave hospital on the same day as having TURBT (however sometimes an overnight stay is necessary) and are able to resume normal physical activity within two weeks.
Blood in the urine and bladder discomfort after TURBT can occur intermittently for up to four weeks following your procedure. This is considered a normal part of the healing process and increasing oral fluids along with rest can help, but if you are concerned, please speak with your urology team.
Intravesical means given directly into the bladder. Depending on your individual circumstances, immediately after TURBT you may be offered a single dose of chemotherapy which is administered directly into your bladder through the indwelling catheter. The most commonly used chemotherapy drug is called Mitomycin C®. Further information can be found on the Macmillan website. Written information can be provided.
Mitomycin C® can only be administered after you have recovered from the effects of the general anaesthetic and any blood in your urine has settled. Mitomycin C® given after TURBT can, in certain circumstances, reduce the risk of bladder cancer returning. The use of intravesical chemotherapy after TURBT would be discussed with you by your surgeons.
If felt to be beneficial, intravesical chemotherapy using Mitomycin C® may also be offered to you later on as part of your ongoing care. This is given as a course of weekly treatments in an outpatient setting. For some patients, but not all, intravesical chemotherapy can be given using electro-motive drug administration (EMDA) or warmed administration (hyperthermia) techniques, or as part of a clinical trial.
Muscle invasive bladder cancer
If you are diagnosed with muscle invasive bladder cancer the treatment options discussed with you may include Radical Cystectomy (operation to remove the bladder), radiotherapy and/or chemotherapy.
The most widely used type of surgery for muscle-invasive bladder cancer is called a radical cystectomy (removal of the bladder). Cystectomy involves removing the entire bladder as well as nearby lymph nodes, part of the urethra, the prostate (in men), and sometimes the cervix, womb and ovaries (in women).
UCLH is one of the few hospitals in the UK that performs cystectomy and reconstruction using the ‘Da Vinci’ robotic surgical system. The robotic system is the most up-to-date technology and was introduced as part of our new robotic surgery programme.
The ‘Da Vinci’ system provides the surgeon with controlled and precise movement. The surgeon is in full control of the system at all times and can operate in highly magnified 3D.
As the robotic surgery is performed laparoscopically (key-hole surgery), we have found that patients benefit from a reduced recovery time and from far less visible scarring.
As your bladder is being removed during a radical cystectomy, your surgeon will need to create an alternative way for the urine to leave your body. This is known as urinary diversion and can include either forming a urinary stoma (an opening on the lower abdominal wall for urine to drain out into a bag) or for some patients making a neo (new)-bladder (an internal reservoir made up of segments of bowel into which urine collects). Choosing the right option from those available can be very difficult, particularly on top the existing worry around the surgery itself. UCLH has a team of highly experienced and dedicated specialist nurses called the urinary diversion team who are there to support you during this time.
Radiotherapy uses pulses of radiation to destroy cancerous cells and is an alternative treatment option for muscle-invasive bladder cancer.
Radiotherapy can be used
- As a primary treatment for muscle-invasive bladder cancer – if you do not wish to undergo radical surgery or if your general health is poor and you are less able to withstand the effects of surgery.
- To help control your symptoms in cases of incurable (metastatic) bladder cancer – this is known as palliative radiotherapy.
As with radical cystectomy surgery, radiotherapy carries its own risks and benefits. If you are considering treatment using radiotherapy, you will be seen by a highly experienced team of oncology (cancer) doctors (also known as clinical oncologists) who will discuss this treatment with you in more depth. Radiotherapy may well be delivered at your local hospital, and this will be discussed with you.
Intravenous chemotherapy involves the administration of a chemotherapy drug into a vein. It will be administered in an outpatient setting by a specialist medical oncology team. Intravenous chemotherapy can be given either before or after cystectomy or radiotherapy. It can also be used as a treatment for metastatic bladder cancer.
Metastatic bladder cancer refers to bladder cancer which has spread to other areas of the body. These can include the lymph nodes, lungs or other organs. There may also be regrowth of the cancer inside the bladder.
Metastatic bladder cancer is not curable, but can be controlled using treatments such a chemotherapy and radiotherapy. Radiotherapy in particular can also help to control any symptoms that may appear as the cancer continues to grow. There may also some newer treatments available which the team can help to identify.
Patients living with metastatic bladder cancer will be offered specialist support from their GP and community palliative care teams. Palliative care refers to care given towards the end of life. Many patients will wish to continue to lead active and productive lives, and palliative care helps to encourage this for as long as is possible. It can also provide support for patients (and their families and friends) when preparing for the end of life, saying goodbye and passing.
