Treatment options for muscle invasive bladder cancer

Muscle invasive means the cancer has spread into or through the muscle layer of the bladder. 

This page is about treatment options for muscle invasive bladder cancer. 

We have a separate section about treating non muscle invasive bladder cancer. Non muscle invasive means the cancer is only in the inner lining of the bladder. It hasn’t spread into the muscle layer of the bladder wall.

The main treatments

You might have one or more of the following treatments for muscle invasive bladder cancer:

• surgery 
• chemotherapy
• radiotherapy
• radiotherapy combined with chemotherapy (chemoradiotherapy)
• immunotherapy

What does bladder sparing treatment mean?

If you have radiotherapy rather than surgery, you might hear your treatment described as ‘bladder sparing’ or ‘organ preserving’ treatment. This is because you still have your bladder at the end of treatment. It is different to surgery, where the surgeon removes your bladder.

Surgery

Most people start by having a trans urethral resection of bladder tumour (TURBT). This surgery diagnoses muscle invasive bladder cancer. And it finds out the stage of your cancer. You might have a second TURBT to make sure the surgeon has removed all the cancer.

Your doctor might then recommend surgery to remove your bladder (cystectomy). This is quite a big operation.

After a cystectomy, you need a new way of collecting urine. You might need to wear a bag to collect urine from an opening on your abdomen (urostomy). Or in some cases, your surgeon can create a new bladder.

Your surgeon will talk to you about ways to collect urine after the operation. They will tell you about the different operations, and what they involve. You might have a choice.

Chemotherapy

Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. The chemotherapy drugs circulate throughout the body in your bloodstream. This is different to having chemotherapy into your bladder for non muscle invasive bladder cancer. 

You might have chemotherapy:

• before surgery or radiotherapy - this is called neoadjuvant chemotherapy 
• alongside radiotherapy, to make the radiotherapy work better - this is called chemoradiotherapy
• after surgery, if you didn’t have it before - this is called adjuvant chemotherapy
• as your main treatment, if your cancer is advanced (metastatic)

Radiotherapy

Radiotherapy uses high energy rays to destroy cancer cells. You might have radiotherapy combined with chemotherapy (chemoradiotherapy) as your main treatment. Or you might have radiotherapy to control symptoms if your cancer has spread. 

Chemoradiotherapy

You usually have radiotherapy with chemotherapy (chemoradiotherapy). This helps the radiotherapy to work better. 

You usually have the chemotherapy during the first and fourth week of radiotherapy. There are different drugs and different ways of giving these drugs.

Immunotherapy

Immunotherapy uses our immune system to fight cancer. It works by helping the immune system recognise and attack cancer cells.

You might have immunotherapy drug such as nivolumab, avelumab or atezolizumab after surgery, or for metastatic cancer.

Deciding which treatment you need

A team of doctors and other professionals discuss the best treatment and care for you. They are called a multidisciplinary team (MDT).

The MDT includes:

• a urologist - a surgeon specialised in treating bladder problems
• an oncologist – a cancer specialist
• a radiologist – a doctor specialising in reporting x-rays and scans
• a specialist urology nurse – also called a clinical nurse specialist (CNS)
• a pathologist - a doctor who specialises in looking at cells under the microscope

The doctors consider many factors, including:

• where your cancer is

• how far it has grown or spread (the stage)

• the type of cancer

• whether you have any carcinoma in situ (CIS) in your bladder

• your general health and level of fitness

• what cancer treatment you’ve had before

• how much urine your bladder can hold

• what symptoms you have from your cancer

Your doctor will talk to you about your treatment, its benefits and the possible side effects.

Choosing between treatments

Your doctor might ask you to choose between:

• surgery to remove your bladder or chemoradiotherapy 
• different ways of collecting urine after surgery if you are having surgery

But you might not have a choice if one or more of the treatments are not suitable for you. This depends on your situation. For example, they might not recommend radiotherapy if:

• you have squamous cell bladder cancer

• there is carcinoma in situ (CIS) in much of the bladder lining as well as invasive cancer

• initial chemotherapy is not working

• the cancer is blocking one or both of the tubes that carry urine into the bladder from the kidneys (ureters)

Talk to your specialist about the risks and benefits of surgery or radiotherapy for you. They will discuss your treatment options with the multidisciplinary team.

You may need to meet with one or more of the specialists in the team to discuss your options. You make the final decision about which treatment you have.

Treatment by stage

Your stage means how far the cancer tumour has grown into your bladder. This is the T stage. The doctors also look at whether the cancer has spread to any lymph nodes. This is the N stage. And whether it has spread to other parts of the body, which is the M stage.

Doctors also describe the stage of muscle invasive bladder cancer as:

• localised
• locally advanced
• advanced (metastatic).

Localised bladder cancer

Localised invasive bladder cancer means your cancer has grown into, but not through, the muscle layer of your bladder (T2). It hasn’t spread to your lymph nodes (N0) or to other parts of your body (M0).

If you are able to have chemotherapy, your doctor will usually offer you:

• a combination of chemotherapy drugs (neoadjuvant chemotherapy)

You then have either:

• surgery to remove your bladder (cystectomy)
• radiotherapy combined with drugs that make it work better (radiosensitisers)

You might have chemotherapy after surgery (adjuvant chemotherapy) if: 

• you didn’t have chemotherapy before your surgery
• your doctor thinks there is a high risk of your cancer coming back.

Your doctor might offer you an immunotherapy drug called nivolumab if you can’t have chemotherapy. And if your cancer has high levels of a protein called PD-L1.

Locally advanced bladder cancer

Locally advanced bladder cancer means your cancer has grown through the muscle layer of your bladder into the fat layer (T3 or T4a). Or it has spread to nearby lymph nodes (N1 to N3). It hasn’t spread to other parts of your body (M0).

You usually have:

• a combination of chemotherapy drugs, if you are able to have chemotherapy

You might have surgery or radiotherapy after your chemotherapy if your doctor thinks these treatments are suitable. Your team will talk to you before you start treatment and discuss whether they think this might be a possibility.    

You might have immunotherapy after your treatment, or instead of chemotherapy. 

Advanced (metastatic) bladder cancer

Advanced (metastatic) bladder cancer means your cancer has spread to the wall of your tummy (abdomen) or between the hips (pelvis) (T4b). Or it has spread to distant lymph nodes or to other parts of the body such as the bones, lungs or liver (M1).

Treatment aims to control your cancer and give you a good quality of life. Your doctor might offer you:

• a combination of chemotherapy drugs
• immunotherapy drugs such as avelumab or atezolizumab
• treatments to control symptoms caused by your cancer, this may include surgery

Your doctor will discuss the advantages and disadvantages of having treatment with you. They will also talk to you about what might happen if you don’t have any treatment.

If your bladder cancer comes back

Your bladder cancer might come back after treatment. Your doctor calls this a recurrence or relapse. The treatment you have depends on:

• where the cancer has come back
• the treatment you had before
• your general health and level of fitness
• your wishes

Some common places it may come back in are the lymph nodes, lungs, liver or bones.

If it comes back after surgery

If muscle invasive bladder cancer comes back after surgery (cystectomy), you might have:

• chemotherapy into a vein 
• radiotherapy to the sites it has come back in
• immunotherapy

Unfortunately, if your cancer comes back after a radical cystectomy it usually can’t be cured. Talk to your doctor or nurse about the treatments that are best for you.

If it comes back after radiotherapy or chemoradiotherapy

If muscle invasive bladder cancer comes back after radiotherapy you might have:

• surgery to remove your bladder (cystectomy)
• chemotherapy into a vein
• immunotherapy

You can't have more radiotherapy if you have already had radiotherapy or chemoradiotherapy.

Clinical trials to improve treatment

Your doctor might ask if you’d like to take part in a clinical trial. Doctors and researchers do trials to make existing treatments better and develop new treatments.