Types of treatment for advanced bladder cancer

For bladder cancer that has spread, you may have chemotherapy, radiotherapy or surgery. Which treatment you have depends on

• How much your cancer has spread
• Where the cancer has spread to in the body
• The treatment you have already had
• Your age and general fitness

If your cancer has grown through the bladder wall or has spread to lymph nodes but no further, removal of the bladder or radiotherapy to the bladder may cure it. As well as treatment to your bladder you may have nearby lymph nodes removed or have radiotherapy treatment to them. These treatments would be followed by chemotherapy into a vein.

If your cancer has spread to another body organ, then unfortunately, treatment is not likely to cure it. But it may shrink the cancer to control it and reduce symptoms for some time. Chemotherapy into a vein goes into the bloodstream and travels throughout the body. Chemotherapy can shrink a tumour and control symptoms. 

Some research trials are giving other biological therapies such as sunitinib or lapatinib alongside chemotherapy to see if it can make the chemotherapy work better.

You may have surgery if the cancer is in the bladder or is blocking urine from passing through your ureters or urethra. Or you may have radiotherapy to the part of the body where the cancer has spread.

Do talk to your specialist or specialist nurse about the treatment choices in your particular situation. If you wonder why a particular type of treatment isn't an option, do ask. Your specialist can then explain this to you.

There has been quite a bit of success using chemotherapy to treat advanced bladder cancer. It can help to control or get rid of advanced bladder cancer for some time. But some types of bladder cancer chemotherapy can be quite intensive. They take a few months and can have a lot of side effects. It is the same types of chemotherapy used for invasive bladder cancer. 

In particular, older people who are less fit may find the side effects of intensive chemotherapy too severe. You may have less intensive types of chemotherapy if you are very unwell because of the cancer, or if you have

• Other medical problems, such as heart, lung or liver problems
• Poor kidney function
• Widespread secondary (metastatic) cancer
• Or cancer severely affecting your liver or lungs

The less intensive types of chemotherapy can still work very well at shrinking the cancer and slowing its growth. You would need to discuss with your own doctor which type of chemotherapy is most suitable for you.

If you had chemotherapy when you were first treated, your doctor will assess how well the chemotherapy worked for you then. Then they can decide whether it is likely to work well now. If the chemotherapy did not work well the first time, it is less likely to be helpful now.

There is detailed information about chemotherapy for bladder cancer in the section about treating invasive bladder cancer with chemotherapy.

Your specialist may suggest radiotherapy if you have advanced bladder cancer that is causing you symptoms. For example, if you have pain from cancer that has spread to a bone. Radiotherapy can work very well in this situation. Sometimes the treatment is given in one session. But some people have a few treatment sessions. The radiotherapy will not cure your cancer but it can improve the quality of your life. It can help to keep the cancer under control in the area of the body that has been treated.

Side effects from radiotherapy depend on which part of the body is treated so it is difficult to give general information about the side effects. When radiotherapy is being given to treat symptoms, doctors try to keep the side effects down to a minimum. If you are having just one treatment, or a short course, you may not have very many side effects at all.

If you had radiotherapy to your bladder and pelvis when you were first treated, then you will probably not be able to have any more to that area. This is because there is a limit to the amount of radiation any part of the body can have. But you can have radiotherapy to another part of the body if necessary.

Look at the section about radiotherapy to control symptoms for more information about this treatment and its possible side effects.

If you still have cancer inside your bladder, or if it has grown back, it can make it painful or difficult to pass urine. The pressure of the cancer growing inside the bladder can be uncomfortable. The cancer may also sometimes bleed. Your specialist may suggest removing most of the cancer to stop the bleeding and slow down the cancer. This is called debulking. The surgery is called transurethral resection (TUR) and is done using a cystoscope.

The TUR is a similar procedure to a cystoscopy. It is done under a general anaesthetic. When you wake up you will have a tube into your bladder (catheter) connected to a flushing system. This flushes out any clots that may form in the bladder after your surgery. You will have some bleeding after this type of surgery for a couple of days. Once it has stopped, the flushing system (irrigation) will be taken down and your catheter will be taken out.

Sometimes the cancer can block your ureters or kidney. This can make urine build up in the kidney and stop it from working properly. But relieving the blockage can help the kidney to work normally again. As well as relieving symptoms, improving your kidney function may mean that you are able to have chemotherapy.

Your doctor may suggest an operation to bypass the blockage caused by the cancer. In one type of operation, the doctor puts a small tube (a stent) inside the ureter to allow the urine to drain. The doctor can sometimes do this with a cystoscope so you won't have a wound afterwards. More commonly, your doctor may put a tube (called a nephrostomy tube) through the skin and into the blocked kidney to drain the urine into a bag outside the body. Then, later on, it may be possible to pass a stent from the kidney into the bladder.

Your doctor will do these procedures to try to relieve your symptoms. So it is important that the benefit will be greater than the drawbacks of having an operation. You and your doctor will need to talk this through beforehand.

If your cancer has spread to your bones your doctor may suggest you have drug treatment. When cancer spreads to the bones it can cause pain and weaken them. When the bones are weaker they break more easily. There are a different treatments you may be able to have that help strengthen your bones and prevent problems. 

Denosumab (pronounced den-oh-sue-mab) is a type of monoclonal antibody. It works by helping to strengthen the bones which lowers the risk of fractures and helps to control pain. You have it as an injection just under your skin (subcutaneously).  There is more information about denosumab including possible side effects in the cancer drugs section.

Bisphosphonates are another type of drug treatment which can help to strengthen bones. You can have them by drip into the bloodstream or you may have them as tablets to take at home. They also help control pain and calcium levels in your blood. The cancer treatments section has information about bisphosphonates.

For some people the treatment aims to cure the cancer. But if your treatment is aiming to slow the cancer and control symptoms it can be difficult to decide which treatment to try, or whether to have treatment at all. You will need to think about how the treatment will affect your quality of life. This includes the possible side effects as well as stresses such as travelling to and from the hospital. Most importantly you will need to understand what can be achieved with the treatment you are being offered.

Your doctor will discuss the options for treatment with you. There may be a counsellor or specialist nurse at the hospital you can chat to. You may also want to talk things over with a close relative or friend. After you have had time to think about the options, you and your specialist will make the final decision together.  It can be helpful to talk over difficult decisions with someone who is outside your circle of family and friends.

Some bladder cancer organisations can give you information about treatment. Or the organisations can put you in touch with cancer support groups where you can talk to other people who have been through similar experiences to your own.