Bladder Cancer

Question 1

What is the recommended treatment for intermediate risk NMIBC?

Answer 1

Induction MMc or BCG

Question 2

In intermediate risk patients who completely respond to induction Chemo or BCG, is maintenance recommended?

Answer 2

Yes, it should be “considered” according to the guidelines.

Question 3

Discuss bladder cancer nodal staging

Answer 3

N1 - single node in true pelvis
N2 - multiple nodes in true pelvis
N3 - nodes to common Iliacs

Question 4

How long should bcg maintenance be performed?

Answer 4

1 year in intermediate risk, 3 years in high risk

Question 5

What is treatment for BCG sepsis?

Answer 5

Admission to hospital
IVF
Steroids
INH 300
Vitamin B6
Rifampin
Ethambutol
Fluoroquinolones for GNR coverage

Question 6

Side effects of BCG?

Answer 6

Irritative voiding
Hematuria 
Dysuria
Low grade fever
Body aches
Granulomatous prostatitis
Cystitis

Question 7

How to improve tolerance of BCG?

Answer 7

Decrease dose to 1/3
Space out treatments
Decrease dwell time

Question 8

Follow up after treatment of MIBC?

Answer 8

Labs every 3 months for 2 years
CXR and CT/MRI every 6 months for 2 years
Urethral washing every 6 months

Question 9

What should be offered to MIBC pts ineligible for cisplatin?

Answer 9

Immediate surgery. Don’t offer carbo?

Question 10

What should be offered to cystectomy patients who have non-organ confined disease and did not get NAC?

Answer 10

Adjuvant chemo

Question 11

Follow up after cystectomy for MIBC?

Answer 11

If non-organ-confined or metastatic offer adjuvant

Otherwise CT a/p every 6 months for 3 years
Labs CBC, CMP, B12 at least every 6 months
Chest imaging annually

Question 12

What perioperative medications should be given to all cystectomy patients?

Answer 12

Alvimopam

Heparin

Question 13

What is required for all patients who are smoking?!!!

Answer 13

Find out the pack-years and counsel them regarding smoking cessation

Question 14

How can you manage irritative voiding symptoms on BCG in a patient who is very uncomfortable?

Answer 14

First you have to rule out infection. If negative, then you can do the following:

• try anticholinergic or myrbetriq
• pyridium
• reduce dose to 1/3 strength
• try giving cipro 6 hours after the BCG
• Tylenol/Advil
• give 1 week off

Question 15

How do you manage a patient who develops fevers on BCG?

Answer 15

If they are bona fide and have been going on for more less than 24 hours, you assume sepsis from a UTI, and you treat them like a UTI sepsis patient.

If they continue for >48 hours then you have to assume they are BCG sepsis and get ID consult, start INH, Etc