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02.19 Bladder Cancer

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Overview

  1. Bladder Anatomy- men and women
    1.  Hollow organ with muscular walls to allow for expansion and contraction
    2. Connected to kidney by ureters
    3.  Urine forced out urethra when bladder contracts 
    4.   Layers of the bladder wall 
      1. Transitional epithelium- urothelium/ innermost layer
      2. Connective tissue- blood vessels and nerves
      3. Muscle
      4. Fatty layer

Nursing Points

General

  1. What is bladder cancer?
    1. An overgrowth of abnormal cells in the bladder 
    2.   Staged with TNM- Tumor size, lymph node involvement, and metastasis 
  2. Has the highest rate of recurrence of any cancer
    1. Is treatable but often returns- some treat it like a chronic condition
  3. Incidence
    1. More common in men
    2. Mainly occurs in the older population- the average age at diagnosis is 73
  4.  Types of Bladder Cancer
    1. Urothelial Carcinomas- starts in cells that line the bladder, most common
    2. Other Types (1-2%):
      1. Squamous Cell Carcinoma- formed from chronic bladder irritation (foleys, infections)
      2. Adenocarcinomas- gland forming
      3. Small Cell- neuroendocrine cells
      4. Sarcoma- start in the muscle of the bladder
  5. Location
    1. Invasive
      1. Growth into deeper layers of the bladder
      2. More difficult to treat
    2. Noninvasive
      1. Only in the inner layer of the bladder- transitional epithelium
  6. Risk Factors and causes
    1. Chemical exposure
      1. Arsenic in water
      2. Aromatic amines- used in dye industry
      3.  Diesel fumes
    2. Genetic mutations
      1. Inherited- not thought to be a major cause
      2. Acquired- more common, can be from exposure to toxin or random
    3. Chronic bladder irritation and inflammation
      1. Infections
        1. UTIs
        2. Schistosomiasis- parasitic worm- common in Africa and Middle East
      2. Chronic foley catheters 
    4. SMOKING- causes half of bladder cancers,
      1. A direct link with bladder cancer

Assessment

  1. Hematuria- Blood in the urine is the first sign
    1. Is often intermittent- bleeding not always constant
  2. Changes to urination from an irritated bladder
    1. Frequency
    2. Pain
    3. Urgency
    4. Difficulty/ weak stream
  3. Signs of spread to other areas
    1. Lower back pain or flank pain
    2.  Bone pain
    3. Lower extremity edema
    4. Palpable mass- rare
  4.  Diagnostics
    1. Urinalysis
      1. Hematuria
    2. Urine cytology and tumor marker
      1. Look for cancer cells or common proteins released by tumors in the urine
    3.  Cystoscopy
      1. Camera inserted through the urethra
      2. Biopsies can be taken (TURBT- transurethral resection of bladder tumor) 
    4. Pyelogram- X-ray of urinary system after dye injected to assess the function
      1. Intravenous- dye injected to vein
      2. Retrograde- dye injected through a catheter

Therapeutic Management

  1. Treatment modalities depend on the stage at diagnosis and are often a combination of treatments
    1. Surgery
      1. TURBT- can lead to bladder scarring and urinary changes
      2. Cystectomy- Removal of the bladder
        1. Partial- a portion of bladder removed
        2. Radical- removed bladder and lymph nodes
          1. In men- removes the prostate and seminal vesicles
          2. In women- removes ovaries, Fallopian tubes, uterus, cervix, and part of the vagina
      3. Reconstructive surgery
        1. Incontinent diversion
          1. Ileal conduit/ urostomy
          2. Stoma on abdomen constant urine release
        2. Continent diversion-
          1. stoma attached to pocket that holds urine until ready to empty
        3. Neobladder- new bladder made with intestines- urine passed through urethra but no urge to pass so it must be done on schedule
    2. Intravesical Therapy- Therapy delivered directly to the bladder via a catheter
      1. Bacillus Calmette-Guerin (BCG)- immunotherapy that activates the immune system to fight cancer cells
        1. Causes flu-like symptoms
        2.  Causes burning/ bleeding with urination
      2.  Chemotherapy- several treatment options to kill cancer cells directly
        1. Some claim more effective if chemo is heated
        2. Causes irritation and burning in bladder
    3.  Radiation
      1. External beam
      2. Causes skin irritation, fatigue, nausea
    4.  Systemic Chemotherapy
      1. Given before or after surgery
      2. Given with or without radiation
      3. Side effects: Nausea, vomiting, fatigue, hair loss from destruction of rapidly dividing cells in the body
    5. Targeted Therapy
      1. Directed at specific cellular mutations causing cancer
      2. Often oral agents

Nursing Concepts

  1. Cellular Regulation
    1. Apoptosis failure leads to cancer growth
  2.  Elimination
    1. Changes d/t cancer and surgical changes
  3. Patient Education-
    1. Consistent follow-up because bladder cancer often comes back 

Patient Education

  1. Smoking cessation- HUGE- smoking has a direct link to bladder cancer

  2. Sexual- change in body image with urostomy, removal of organs and nerves with surgery might prevent orgasm in men and women 

  3. Treatment specific- ensure they understand what to expect following treatments and reasons to return to the clinic or hospital 

Reference Links

Study Tools

Video Transcript

All right. Hi guys. My name is Stephanie and today we’ll be talking about bladder cancer. So let’s click do a little review of what we’re looking at here. So this is the bladder, right? Men and women both have a bladder. Of course it collects urine from the kidneys where the Yarters that drain into the bladder. And we have this detrusor muscle here around the bladder that will contract to release the urine through the urethra. Now there’s different layers of the bladder here. This is showing what those layers look like. So the layer that’s closest to the inside of the bladder is this transitional epithelium. And this is where 98% of bladder cancers form within these cells here. So are we talking more about this type of bladder cancer? If it’s contained within this layer, within these cells on the outside, it’s noninvasive, if it starts spreading to different layers to these other layers here then, or to the muscle itself or to other organs, then it’s called invasive. 

And obviously it’s much harder to treat the invasive bladder cancer than if it’s noninvasive and contained here. Now, some facts about bladder cancer, all cancers growth of abnormal cells, right? Something’s not working to turn off the abnormal cell growth and it goes out of control. It stays with the T N M system. And that’s the tumor size. If it has a lymph node involvement, or if there is metastasis and recurrence is very likely bladder cancer has the highest rate of recurrence of any cancer. So that’s important to note it is treatable, but it often returns. Okay. So some risk factors. Smoking is huge. Smoking is directly linked to bladder cancer. I’ve worked with an oncologist who basically told her patients, you might as well not even treat it. If you’re going to continue smoking, it’s going to come back. It’s going to be aggressive. 

Smoking directly is linked to bladder cancer. Also not drinking enough water. And this makes sense, right? We’re not flushing out our bladder. We’re not making enough urine. If we’re not drinking enough water, we need to make sure we’re flushing out that bladder or flushing out those abnormal cells, chemical exposure. Some chemicals have been directly linked to bladder cancer. And those include arsenic, arsenic, sorry, guys, can’t spell. And that has actually been found in some drinking water, different chemicals that are used in the dye industry. So that would be relevant for people who like dye here, leather, fabric, that sort of thing. And then diesel fume exposure has also been linked to bladder cancer. Genetic mutations have also been linked, but they found they’re not often passed down or inherited. Oftentimes they are acquired over time. Some mutation occurs and then bladder inflammation. This is a big one, and this really makes sense to me. 

So if we’re having chronic inflammation, we’re having the opportunity for cellular changes. If we’re always inflamed. So this can be from infection. So chronic UTI, or actually there’s a parasite that has been found to be linked to bladder cancer. That’s actually not found here, but more in Africa or the middle East. And then also chronic Foleys can cause that chronic irritation and inflammation and have been linked to bladder cancer. What are going to see in a patient with bladder cancer, they’re going to present with hematuria often pretty much throughout their whole course of having bladder cancer. They’re going to have hematuria, which is bled in the urine big ones for bladder cancer. Okay. And then also changes to urination. And these two make sense to me also, because of course there’s cancer cells within that bladder that are going to be causing it to bleed causing irritation, pain, frequency, urgency changes to urination can occur. 

Fatigue is a big one. My dad, like I said, had bladder cancer. Fatigue was his probably number one complaint. Long before we knew he had bladder cancer. He just felt wiped out. His body was trying to fight it right now. If it has spread to other areas, we can have a bunch of different symptoms, but the most common is flank pain fit, spread around the kidneys, right? Or bone pain. If it has spread to the bones,  lower extremity edema is another one. And that’s a bit of spread to the lymph system. Might not make sense until you think about it. But if we’re blocking the lymph system from draining, all of that lymph fluid is going to pool within the lower extremities. And then we might feel a mass that’s actually pretty rare, but it’s possible. Okay. And how is it diagnosed? So first we look at the urine, the urinalysis and your insight, your analysis, and urine cytology. 

So the urinalysis will discover blood in the urine. Even before we can see with her eyes, we might see it in a year analysis. And then you’re in cytology, we’ll look at cancer cells or proteins released by tumors within the urine itself. A cystoscopy is done. That’s what this picture is of it’s inserted through the urethra, kind of like a catheter, right? It’s a camera that looks at the bladder and the cells, and it can take a little sample, a tissue sample to assess it. And then a pilot Graham is a type of x-ray that’s done after dye is injected either into the vein or through a catheter. And then an X Ray is taken to assess the urinary system treatments for bladder cancer. An option is surgery. So if it’s contained within the bladder, we can do this T U R B T. This is a transurethral resection of the bladder tumor. And that’s done just like that last picture we saw just like this [inaudible], but they can actually remove the tumor. Instead of just taking a sample. Cystectomy is removal of the bladder.

Now this can be partial or full, or I can also be radical so they can take a piece of the bladder. They can take the whole thing, or it can be a radical cystectomy. And that also is going to remove some sex organs. So in nails, that would be the prostate females. We would remove the ovaries fallopian tube, uterus, the sex organs. And this is based on the stage of cancer where it has spread to right, what type of surgery they’re going to choose and removing the bladder. We need to talk about reconstructive surgery. So how are they going to get rid of that urine? This picture is one option. This is called neobladder. And this is so cool that surgeons have developed this technique. So they take a piece of the small intestine and they create this pouch, a new bladder. Basically they attach it to the kidneys, through the ureters in the urine can be drained right through the urethra. 

It’s important to note with a neobladder and that they will not get the urge to void. So it needs to be scheduled and they can also avoid the rest stoma, an ilial conduit, right? That can be, continent if there’s out within the stomach or right underneath the skin to collect the urine or incontinent. If there, if there’s a bag right on the outside of this stomach and thoughts of what drains right into the bag, that would be incontinent, stoma, okay. Other treatments besides surgery, we can do intravesical therapy. That’s specific to bladder cancer and that’s therapy. That’s given right to the bladder. This can be immunotherapy, which is often called BCG. It’s a type of immunotherapy that is used or chemo directly into the bladder. So BCG or immunotherapy is going to activate the body to fight against the cancer. And the chemo is going to destroy the cancer cells directly. 

Both of those can cause irritation and bleeding of the bladder. After you get them. Radiation treatment is something that can be used. It’s external beam, radiation not to use. And you can check out the nursing.com lecture about radiation therapy to talk about those side effects, systemic chemo. This is going to destroy all fast growing cells. So with the systemic chemo, we’ll get the nausea, vomiting, hair loss, that sort of thing. And then targeted therapy is actually usually oral agents, oral antique cancer medications usually tolerated much better than systemic chemotherapy patient education for someone with bladder cancer, if they are smoking huge, huge, huge chattin about smoking cessation stops smoking. It is feeding your bladder cancer sexual education. So we need to be able to have this conversation with our patients about sexual changes. If they have a urostomy, if they have that stoma, what, what kind of changes are they going to expect? 

And then treatment specific. So depending on what they have, this is going to be treatment specific. If they had systemic chemo, if they had surgery, if they have radiation, that sort of thing, nursing concepts, we need to talk about with bladder cancer, cellular regulation, right? Cancer at all, something went wrong with the way that our body gets rid of abnormal cells. Elimination is huge. This has changed significantly after surgery, especially to remove the bladder, patient education big, big, big, because bladder cancer tends to return. We need to educate about followup. And then like we talked about on the last side also about their specific treatments. Okay. And some key points for bladder cancer. It has the highest recurrence rate of any cancer. Often treated like a chronic disease. It does often come back. There’s a direct link to smoking. Stop smoking, right? Big one specific to bladder cancer is intravesical chemo directly or immunotherapy, like we said, right directly into the bladder. And then he, materia is a big one. So blood in the urine is a big thing we see with bladder cancer. All right, guys, that’s all I have for you. We love you. Go out and be your best self today. And as always happy nursing.

 

 

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