WELCOME

Bladder Cancer

INTRODUCTION

GENERAL OBJECTIVE: To gain in depth knowledge regarding

CANCER OF URINARY BLADDER.

SPECIFIC OBJECTIVES:

SPECIFIC OBJECTIVES: After completing the seminar students will be able to:

Enumerate the etiological factors of urinary bladder cancer (ca. bladder),

Illustrate clinical manifestations. Describe the management of Ca bladder To enlist the complications occurring due

to same disease

DEFINATION

Bladder cancer is a cancerous tumor in the bladder -- the organ that holds urine

Epidemiology of Bladder CA

4th most common CA in men, 9th in women,

Annual New Cases = 68,810 (51,230 in M & 17,580 in F) M:F = 3:1

Annual Deaths = 14,100 (7,750 in M & 4,150 in F)

Risk Factors for Bladder CA

Age, Gender, Race

Cigarette smoking (2-4x higher relative risk)

Exposures to environmental carcinogens: Occupational - Polycyclic aromatic hydrocarbons,benzene,

exhaust from combustion gases, aryl amines dry cleaners; manufacturers of preservatives, dye, rubber, & leather;

pesticide applicators; painters; truck drivers; hairdressers; printers; machinists

Pelvic radiation therapy Arsenic (eg. in drinking H2O)

Risk Factors for Bladder CA

Infections Schistosoma haematobium (N Africa) Inc’d risk for

squamous & transitional cell CAR Chronic UTIs, chronic bladder stones, indwelling Foleys

inc’d risk for squamous cell CAR

Other Prior h/o bladder CA Low fluid intake (inc’d exposure to carcinogens via dec’d

bladder emptying) Genetics (eg, Retinoblastoma gene) Bladder birth defects (eg, persistent urachus) inc’d risk

for adenocarcinoma.

ANATOMY AND PHYSIOLOGY

Pathophysiology

Clinical Manifestations of Bladder CA Hematuria (80-90%) – Generally painless and gross

hematuria However, 20% can have only microscopic hematuria

Other urinary Sxs Frequency, urgency, nocturia – d/t irritative Sxs or dec’d

bladder capacity

Pain (less common & often reflects tumor location) Lower abdominal pain – Bladder mass Rectal discomfort & perineal pain – Invasion of prostate or

pelvis. Flank pain - Obstruction of ureters

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Lower extremity edema from iliac vessel compression,

Physical: occasionally an abdominal or pelvic mass may be palpable.

Dx of Bladder CA

Pts w/ hematuria, especially if > 40 yrs Urinary Cytology- microscopy, culture to rule out

infection,

USG- abdomen & pelvis,

CT abdomen & pelvis with preinfusion & post infusion phases,

Cystoscopy, regardless of cytology results (mainstay of dx)

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Retrograde pyelography in patients in whom contrast CT scan can’t be performed because of azotemia or due to severe allergy to IV contrast,

Transurethral resection of all visible tumors to determine histology & depth of invasion

Biopsies of erythematous (& possibly normal) areas to assess for CIS

STAGES Stage 0 -- Non-invasive tumors that are only in the bladder

lining

*Stage I -- Tumor goes through the bladder lining, but does not reach the muscle layer of the bladder

*Stage II -- Tumor goes into the muscle layer of the bladder

*Stage III -- Tumor goes past the muscle layer into tissue surrounding the bladder

*Stage IV -- Tumor has spread to neighboring lymph nodes or to distant sites (metastatic disease)

Stage V--*Prostate 2)Rectum 3)Ureters 4)Uterus 5)Vagina 6)Bones 7)Liver 8)Lungs

Treatment: Medical(Ta, T1, CIS): non muscle invasive1. Intravesical immunotherapy:

Indications Adjuvant tx w/ resection to prevent recurrence Eliminate disease that cannot be controlled by

endoscopic resection alone (less common) Recurrent disease, > 40% involvement of

bladder surface, diffuse CIS, T1 dz Generally not needed for solitary papillary

lesions

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Agents Std agent -- BCG

Generally 6 weekly txs then monthly maintenance x 1-3 yrs

Toxicities = Bladder irritability / spasm, hematuria, dysuria, & rarely systemic TB

Other agents – Mitomycin-C, Interferon, Gemcitabine

For muscle invasive disease (T2 & greater) Neo-adjuvant chemo x 12 wks prior to

cystectomy Inc’d 5-yr dz-free survival MVAC (Methotrexate, Vinblastine,

Doxorubicin, Cisplatin) – 3 cycles q 28 days

Surgical Rx: For Ta, T1, CIS (non muscle invasive)1. Endoscopic treatment: TURBT- To dignose, to stage, to treat visible

tumors. Electrocautry or LASER fulguration of bladder

is sufficient for low grade, small volume tumors.

2. Radical cystectomy: Patients withunresectable, prostatic urethra

involvement & BCG failure are indications for this procedure.

Muscle invasive disease: T2 & greater

1. Radical cystoprostectomy: (men) Remove the bladder, prostate & pelvic

lymph nodes. After removal of bladder, urinary diversion

must be created. Types:

Continent,

Incontinent.

2. Radiation therapy:

External beam radiation therapy has been shown to be inferior to radical cystectomy.

Complications:

Body image disturbances, Skin irritation, Recurrence, Infertility in women as uterus is removed, Infertility in men if prostate is removed, Menopause if ovaries are removed, Sexual disturbances if vagina has been made

shorter, Metastasis to distant organs.

Nursing Diagnosis:

Dysurea related to disease condition, Disturbed sleep pattern due to urgency &

frequency of micturition, Acute pain related to disease condition, Altered nutrition secondary to pain due to

disease condition, Anxiety related to surgery, Disturbed body image related to surgery.

Research evidence:

A research carried out by “Yursh Xia 4th military medical university” states that, “Adjuvant Radiotherapy in addition to cystectomy also increases survival rates.”

A research by “Dept of Urology Health Science, Centre West Virginia Morgan Town” says that “Garlic can be used an immunotherapy besides BCG.”

SUMMARY

CONCLUSION

Harrison’s Internal Medicine Cecil Textbook of Medicine Cancer: Principles & Practice of Oncology National Cancer Institute website American Cancer Society website

THANK YOU