Page last updated: May 2024
The information on this webpage was adapted from Understanding Bladder Cancer - A guide for people with cancer, their families and friends (2024 edition). This webpage was last updated in May 2024.
Expert content reviewers:
This information was developed based on international clinical practice guidelines, and with the help of a range of health professionals and people affected by bladder cancer:
- Dr Prassannah Satasivam, Urologist and Robotic Surgeon, Epworth Hospitals and Cabrini Hospitals, VIC
- Donna Clifford, Urology Nurse Practitioner, Royal Adelaide Hospital, SA
- Marc Diocera, Genitourinary Nurse Consultant, Peter MacCallum Cancer Centre, VIC
- Dr Renee Finnigan, Radiation Oncologist, Gold Coast University Hospital, QLD
- Lisa Hann, 13 11 20 Consultant, Cancer Council SA
- Dr Andrew Hirschhorn, Director of Allied Health and MQ Health Academy, MQ Health, Macquarie University, NSW
- Anne Marie Lyons, Stomal Therapy Nurse, Concord Hospital and NSW Stoma Limited, NSW
- John McDonald, Consumer
- Prof Manish Patel, Urological Cancer and Robotic Surgeon, Westmead Hospital, Macquarie University Hospital, and The University of Sydney, NSW
- Dr Jason Paterdis, Urological Surgeon, Brisbane Urology Clinic, QLD
- Graeme Sissing, Consumer
- Prof Martin Stockler, Medical Oncologist, The University of Sydney, Concord Cancer Centre, and Chris O’Brien Lifehouse RPA, NSW
If cancer cells are found only in the inner layers of the bladder, the cancer is called superficial or non-muscle-invasive bladder cancer (NMIBC). The main treatment is surgery to remove the cancer, often done during diagnosis.
Surgery is commonly combined with chemotherapy or immunotherapy, which is delivered directly into the bladder (intravesical).
Surgery (TURBT)
Most people with superficial bladder cancer have an operation called transurethral resection of bladder tumour or TURBT. This procedure is usually done during diagnosis.
If the cancer has spread to the lamina propria or is high grade, you may need a second TURBT 2–6 weeks after the first procedure to make sure that all cancer cells are removed.
If the cancer comes back after initial treatment, your surgeon may do another TURBT or suggest removing the bladder in an operation called a cystectomy.
Check-ups after surgery
Cancer can come back even after a TURBT has removed it from the bladder. You will need regular follow-up cystoscopies to find any new tumours in the bladder as early as possible. This approach is known as surveillance cystoscopy.
How often you need to have a cystoscopy will depend on the stage and grade of the cancer, and how long since it was diagnosed.
Intravesical chemotherapy
Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells.
Chemotherapy drugs are usually injected into a vein or given as tablets. In intravesical chemotherapy, the drugs are put directly into the bladder using a catheter (a thin, flexible tube) inserted through the urethra.
Intravesical chemotherapy is used mainly for low-risk to medium-risk superficial bladder cancer. It helps prevent the cancer coming back (called a recurrence). Each dose is called an instillation, and this is usually given in a day procedure in hospital.
People with a low risk of recurrence usually have one instillation straight after TURBT surgery. The chemotherapy solution is left in the bladder for 1–2 hours and then drained out through a catheter or by urinating after the catheter has been removed.
You may be asked to change position every 15 minutes so the solution washes over the whole bladder. People with a medium risk of recurrence may have instillations once a week for 6 weeks.
While you are having a course of 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 spread through the whole body). The main side effect of intravesical chemotherapy is inflammation of the bladder lining (called cystitis).
Signs of cystitis include wanting to pass urine more often or having a burning feeling when urinating. Drinking plenty of fluids 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 you notice any side effects while on intravesical chemotherapy.
Intravesical immunotherapy (BCG)
Immunotherapy is treatment that uses the body’s own natural defences (immune system) to fight disease. Bacillus Calmette-Guérin (BCG) is a vaccine that was originally used to prevent tuberculosis. It can also stimulate a person’s immune system to stop or delay bladder cancer coming back or becoming invasive.
The most effective way to treat high-risk superficial bladder cancer is with a combination of BCG and TURBT, where BCG is given once a week for 6 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 whole bladder. This is usually done as a day procedure in hospital, and each treatment session takes up to 2 hours.
BCG safety at home
The BCG vaccine contains live bacteria, which can harm healthy people, so your treatment team will tell you what safety measures to follow at home. Speak to your medical team if you have any questions.
- Take care going to the toilet – For six hours after BCG treatment, sit down on the toilet when urinating to avoid splashing. When finished, pour two cups of household bleach (or a sachet of sodium hydrochlorite if provided by your treatment team) into the toilet bowl. Wait 15 minutes before flushing with the toilet lid closed. Wipe the seat with disinfectant. If clothing is splashed with urine, wash separately in bleach and warm water.
- Handle incontinence pads carefully – If you use incontinence pads, for a few days after treatment 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. Tie up the bag and put it in your rubbish bin. You may also be able to take the sealed bag back to the hospital or treatment centre for disposal in a biohazard bin.
- Wash hands well – For a few days after each treatment, wash your hands extra well after going to the toilet, and wash or shower with soap and water if your skin comes in contact with urine.
- Drinks fluids – To help clear the BCG from your body drink plenty of liquids for 6–8 hours after treatment.
- Practise safe sex – For a week after each treatment, use barrier contraception (condoms) to protect your partner from any BCG that may be present in your body fluids and to prevent pregnancy.
Ongoing BCG treatment
For most people with high-risk superficial bladder cancer, the initial, six-week course of BCG treatments is followed by more BCG. This is called maintenance BCG and it reduces the risk of the disease coming back or spreading.
Maintenance treatment can last for 1–3 years, but treatment sessions become much less frequent (e.g. one dose a month). Treatment schedules can vary so ask your doctor for further details.
Side effects of BCG
Common side effects of BCG include:
- needing to urinate more often
- burning or pain when urinating
- blood in the urine
- a mild fever
- tiredness.
These side effects usually last a couple of days after each BCG treatment session. Less often, the BCG may spread through the body and can affect any organ.
If you develop flu-like symptoms, such as fever over 38°C that lasts longer than 72 hours, pain in your joints, a cough, a skin rash, tiredness, or yellow skin (jaundice), contact a nurse or doctor at your treatment centre immediately. A BCG infection can be treated with medicines.
Very rarely, BCG can cause infections in the lungs or other organs in the body months or years after treatment. If you are diagnosed with an infection in the future, it is important to tell the doctor that you had BCG treatment.
Let your doctor know of any other medicines or complementary therapies you are using, 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.
Advanced bladder cancer treatment
If bladder cancer has spread to other parts of the body, it is known as advanced or metastatic bladder cancer. Treatment will focus on controlling the cancer and relieving symptoms without trying to cure the disease.
This is called palliative treatment and it can include systemic chemotherapy, immunotherapy, surgery and radiation therapy.
Many people think that palliative treatment is only for people at the end of their life, but it may help people at any stage of advanced bladder cancer. It is about living as comfortably as possible and helping you to maintain your quality of life.
Learn more about advanced cancer
Immunotherapy for advanced NMIBC
Immunotherapy uses the body’s own immune system to fight cancer. BCG is a type of immunotherapy treatment that has been used for many years to treat superficial bladder cancer.
A newer group of immunotherapy drugs called checkpoint inhibitors work by helping the immune system to recognise and attack the cancer.
Some people with advanced bladder cancer may have checkpoint immunotherapy drugs such as pembrolizumab or avelumab after a course of chemotherapy.
The drugs are given directly into a vein through a drip (infusion) and the treatment is repeated every 2–6 weeks. How many infusions you receive will depend on how you respond to the drug.
Some drugs may be available through clinical trials for people with bladder cancer that has come back or not responded to treatment. Ask your doctor about recent developments in drugs for bladder cancer and whether a clinical trial may be an option for you.
Systemic chemotherapy for advanced NMIBC
Enfortumab vedotin is a new type of chemotherapy. Known as an antibody-drug conjugate (ADC), enfortumab vedotin targets a particular protein (called nectin-4) on cancer cells.
You do not need to have tests to see if the cancer has this protein before having this drug. Enfortumab vedotin may be used for people with advanced bladder cancer that has not responded to other types of systemic chemotherapy and immunotherapy. It is given in the same way as other types of systemic chemotherapy.
Side effects of enfortumab vedotin may include:
- skin rashes
- nausea and vomiting
- high blood sugar
- shortness of breath or trouble breathing
- eye problems such as blurred vision
Let your treatment team know if you notice these or any other side effects.
