bladder cancer word.docx

Cancer of the Bladder Twenty-five percent of cancers of the urinary bladder occur in adults older than 65 years (Caruso, Tyler, & Wolkowicz, 2017). It is the sixth most common cancer with a much higher incidence in men than women for reasons that are still not well understood (National Cancer In...

Cancer of the Bladder Twenty-five percent of cancers of the urinary bladder occur in adults older than 65 years (Caruso, Tyler, & Wolkowicz, 2017). It is the sixth most common cancer with a much higher incidence in men than women for reasons that are still not well understood (National Cancer Institute [NCI], 2020). Bladder cancer is a leading cause of death, accounting for more than 15,000 deaths in the United States annually (NCI, 2020). Cancers arising from the prostate, colon, and rectum in males and from the lower gynecologic tract in females may metastasize to the bladder. Tobacco use, especially cigarettes, continues to be a leading risk factor for all urinary tract cancers (NCI, 2020) (see Chart 49-12). Clinical Manifestations Bladder tumors usually arise at the base of the bladder and involve the ureteral orifices and bladder neck. Visible, painless hematuria is the most common symptom of bladder cancer. Infection of the urinary tract is a common complication, producing frequency and urgency. However, any alteration in voiding or change in the urine may indicate cancer of the bladder. Pelvic or back pain may occur with metastasis. Assessment and Diagnostic Findings The diagnostic evaluation includes cystography, excretory urography, CT and MRI scans, ultrasonography, and bimanual examination with the patient anesthetized. Noninvasive detection using molecular markers is currently under investigation (Caruso et al., 2017). Biopsies of the tumor and adjacent mucosa are the definitive diagnostic procedures (NCI, 2020; Norris, 2019). Transitional cell carcinomas and carcinomas in situ shed recognizable cancer cells. Cytologic examination of fresh urine and saline bladder washings provides information about the prognosis and staging, especially for patients at high risk for recurrence of primary bladder tumors. See Chapter 12 for more information on cancer grading and staging. Medical Management Treatment of bladder cancer depends on the grade of the tumor (the degree of cellular differentiation) and the stage of tumor growth (the degree of local invasion and the presence or absence of metastasis) (NCI, 2020). The patient’s age and physical, mental, and emotional status are considered when determining treatment modalities. Surgical Management Transurethral resection or fulguration (cauterization) may be performed for simple papillomas (benign epithelial tumors) (Caruso et al., 2017). These procedures eradicate the tumors through surgical incision or electrical current with the use of instruments inserted through the urethra. After this bladdersparing surgery, intravesical administration of bacille Calmette–Guérin (BCG) is the treatment of choice. BCG Live is an attenuated live strain of Mycobacterium bovis, the causative agent in tuberculosis; treatment is recommended for a minimum of 1 year (NCI, 2020). The exact action of BCG is unknown, but it is thought to produce a local inflammatory and a systemic immunologic response. Management of superficial bladder cancers presents a challenge because there are usually widespread abnormalities in the bladder mucosa. The entire lining of the urinary tract, or urothelium, is at risk because carcinomatous changes can occur in the mucosa of the bladder, kidney pelvis, ureter, and urethra. A simple cystectomy or a radical cystectomy is performed for invasive or multifocal bladder cancer. Radical cystectomy in men involves removal of the bladder, prostate, and seminal vesicles and immediate adjacent perivesical tissues. In women, radical cystectomy involves removal of the bladder, lower ureter, uterus, fallopian tubes, ovaries, anterior vagina, and urethra. It may include removal of pelvic lymph nodes. Removal of the bladder requires a urinary diversion procedure, which is described later in this chapter. Although radical cystectomy remains the standard of care for invasive bladder cancer in the United States, clinical trials continue to explore other options in an effort to spare patients the need for radical cystectomy (NCI, 2020). Other options for managing transitional cell bladder cancer mandate lifelong surveillance with periodic cystoscopy. Although most patients respond completely and their bladders remain free from invasive relapse, one fourth develop a relapse of noninvasive disease. This may be managed with transurethral resection of the bladder tumor and intravesical therapies but carries an additional risk that a late cystectomy may be required. Pharmacologic Therapy Chemotherapy with a combination of methotrexate, 5-fluorouracil, vinblastine, doxorubicin, and cisplatin has been effective in producing partial remission of transitional cell carcinoma of the bladder in some patients. IV chemotherapy may be accompanied by radiation therapy (NCI, 2020). Topical chemotherapy (intravesical chemotherapy or instillation of antineoplastic agents into the bladder, resulting in contact of the agent with the bladder wall) is considered when there is a high risk of recurrence, when cancer in situ is present, or when tumor resection has been incomplete. Topical chemotherapy delivers a high Live) to the tumor to promote tumor destruction. Bladder cancer may also be treated by direct infusion of the cytotoxic agent through the bladder’s arterial blood supply to achieve a higher concentration of the chemotherapeutic agent with fewer systemic toxic effects (Blair, 2017; NCI, 2020). BCG Live is now considered the most predominant and conservative intravesical agent for recurrent bladder cancer, especially superficial transitional cell carcinoma, because it is an immunotherapeutic agent that enhances the body’s immune response to cancer. BCG Live has a 43% advantage in preventing tumor recurrence, a significantly better rate than the 16% to 21% advantage of intravesical chemotherapy. In addition, BCG Live is particularly effective in the treatment of carcinoma in situ, eradicating it in more than 80% of cases. In contrast to intravesical chemotherapy, BCG Live has also been shown to decrease the risk of tumor progression. Although BCG Live treatment is the current standard of care, this treatment is most effective when some form of maintenance therapy is utilized (Caruso, et al., 2017; NCI, 2020). The optimal course of BCG Live appears to be a 6-week course of weekly instillations, followed by a 3-week course at 3 months for tumors that do not respond. In high-risk cancers, maintenance BCG Live given in a 3-week course at 6, 12, 18, and 24 months may limit recurrence and prevent progression. However, the adverse effects associated with this prolonged therapy may limit its widespread applicability. The patient is allowed to eat and drink before the instillation procedure. Once the bladder is full, the patient must retain the intravesical solution for 2 hours before voiding. At the end of the procedure, the patient is encouraged to void and to drink liberal amounts of fluid to flush the medication from the bladder.