Week 13: Chp 63: Bladder Cancer Flashcards
Most important risk factor for Bladder cancer
smoking
Risk factors for Bladder Cancer
aromatic amine exposure from the rubber and chemical industries, polycyclic aromatic hydrocarbon exposure from the coal and aluminum industries, chronic infection or inflammation from chronic catheter use, or incomplete bladder emptying
-In some third-world countries, schistosomiasis, a parasitic infection, is the leading risk factor
Pathophysiology of Bladder Cancer
tumor formation in bladder cancer is attributed to genetic changes in target cells
- target cells are normal cells of the body that have undergone some alteration, synthesize abnormal proteins, and then undergo malignant changes
- the process is thought to be caused by the activation of oncogenes (genes that when altered promote the uncontrolled proliferation of cancer cells) that act in one of two ways: by inactivation of tumor suppression genes or by activation of genes that cause cells to grow in a rapid, random manner
What system is used for staging all types of cancer
The tumor, nodes, metastasis (TNM) staging system
Bladder Cancers are classified as?
- non-muscle invasive cancer (T1), affecting the inner lining of the bladder (urothelium)
- muscle invasive cancer (T2-T4), the cancer has extended through the urothelium and into the detrusor muscle
Most common presenting symptoms of bladder cancer
painless hematuria
Diagnostic Tests
- urine cytology
- blood and urine tests (to look for tumor markers)
- urine cultures (to rue out infection)
- cystoscopy (this is coupled with a biopsy of any lesions that are discovered during the examination)
What diagnostic test is used to make a definitive diagnosis?
cystoscopy
-examination of the bladder with a scope
Imaging Studies
-CT
-magnetic resonance imaging (MRI)
-positron emission tomography
-ultrasound
>these may be used to determine whether there is spread of the cancer outside the bladder
Drug therapy for low-grade bladder cancers
- topical therapy or installations of solutions into the bladder, intravesical therapy
- this can be either intravesical immunotherapy or chemotherapy
- Intravesical immunotherapy, such as bacille Calmette-Guerin (BCG), is aimed at “jumped starting” the body’s own immune defenses to battle the invasion of cancer
- Intravesical chemotherapy instills medications given to kill actively growing
Intravesical Immunotherapy; Bacille Calmette-Guerin (BCG)
used for low-grade bladder cancers
-aimed at “jump starting” the body’s own immune defenses to battle the invasion of cancer
Intravesical Chemotherapy
used for low-grade bladder cancers
-instills medications given to kill actively growing cancer cells
Treatment for later-stage bladder cancer
-systemic immunotherapy
Systemic Immunotherapy
treatment for later-stage bladder cancer
- in a healthy individual, “check point” molecules keep the immune system from attacking the body’s normal cells; cancer cells avoid being attacked by the immune system by using these checkpoint molecules
- systemic immunotherapy targets checkpoint molecules
ex: atezolizumab (Tecentriq), durvalumab (Imfinzi), avelumab (Bavencio), nivolumab (Opdivo) and pembrolizumab (Keytruda)
Management and Treatment for high-grade metastatic bladder cancer
- precision medicine
- target therapy (individuals with cancers that are likely to recur are candidates)
Target Therapy
- used for high-grade metastatic bladder cancer
- directed at changes in cells that cause them to become cancer: lapatinib (Tykerb) and erlotinib (Tarceva)
- this therapy may also target blood vessels that carry nutrition to the cancer cells using antiangiogenesis drugs; ex: bevacizumab (Avastin), Sorafenib (Nexavar), cabozantinib (Cometriq), and pazopanib (Votrient)
Safety Alert for Bacille Calmette-Guerin
its a live, weakened bacterium
-to ensure that others are not infected by the bacteria, after voiding following treatment, the patient should pour 2 cups of bleach into the toilet and allow it to sit for 20 minutes before flushing
Surgical Interventions for low-grade bladder cancers consist of?
excision or removal of the tumor through fulguration or laser ablation
>fulguration destroys the tumor by using high-frequency electrical current
>laser ablation destroys tissue by irradiating it with a laser beam
Fulguration
used for low-grade bladder cancers
-destroys the tumor by using high-frequency electrical current
Laser ablation
for low-grade bladder cancers
-destroys tissue by irradiating it with a laser beam
What is done prior to treatment
a biopsy is done to determine the depth of the invasion
- intravesical chemotherapy may be given before surgical excision (neoadjuvant) or after surgical excision (adjuvant)
- radiation is indicated postoperatively
Muscle-invasive bladder cancer treatments
- “bladder preservation” (may be combined with radiation and/or chemotherapy)
- Chemotherapy
- radiation is indicated postoperatively in those patients who have solid tumor recurrence after cystectomy
“Bladder preservation”
-used for muscle-invasive bladder cancer
-
Chemotherapy
is indicated to downgrade tumors preoperatively or to help eradicate cancer that has spread beyond the bladder either grossly (visible to the eye) or microscopically through the lymphatic system
Radiation is indicated postoperatively for which patients?
in those patients who have solid tumor recurrence after cystectomy
Radical Cystectomy combined with neoadjuvant chemotherapy
- another approach for surgical management of invasive bladder cancer
- considered to be the definitive approach; offers the best chance of cure or extension of the disease-free state
- in males its called radical cystoprostatectomy
- in females its called radial cystectomy or anterior exenteration
Radical Cystoprostatectomy
radical cystectomy combined with neoadjuvant chemotherapy
- procedure for males
- surgical management of invasive bladder cancer
- removal of bladder, prostate, seminal vesicles, lower ureters, and in some cases the urethra
- involve pelvic lymph node dissection
- surgical management for invasive bladder cancer
Radical cystectomy or anterior exenteration
radical cystectomy combined with neoadjuvant chemotherapy
- procedure for females
- removal of the bladder, ovaries, fallopian tubes, anterior wall of the vagina, lower ureters, and often urethra
- involve pelvic lymph node dissection
- surgical management for invasive bladder cancer
Urinary Tract Reconstruction Options
- Ileal Conduit
- Orthotopic Neobladder
- Neobladder with Continent Catheterizable stoma
Urinary Tract Reconstruction Options: Ileal Conduit
uses a short segment of ileum to provide a viaduct for the exit of urine from the body through a stoma on the abdomen
>Advantages: simplest “tried and true” procedure; fewest complications
>Disadvantages: external pouch, stoma; adhesives may cause skin irritation; lifelong equipment (pouches, drainage bag) required
>Bowel used: 10-15 cm of terminal ileum
Urinary Tract Reconstruction Options: Orthotopic Neobladder
uses 20 to 30 cm of small intestine to create a bladder that is anatomically in the same position as the native bladder and uses the patient’s external sphincter for continence
>Advantages: no external pouch; most closely resembles “normal” urination
>Disadvantages: may require intermittent catheterization; may require physical therapy for sphincter training; may not achieve continence
>bowel used: 30 cm of ileum
Urinary Tract Reconstruction Options: Neobladder with Catheterizable stoma
a neobladder with Catheterizable stoma and an internal pouch to collect urine
>Advantages: no external pouch; stoma often placed in umbilicus, not visible
>Disadvantages: stoma may not be continent; strictures at skin level may occur; catheter required to empty the internal pouch at regular intervals; option most fraught with complications
The nurse understands that non-muscle cancers affect only:
A. muscle and surrounding fat
B. the urothelium, or inner lining of the bladder
C. structures adjacent to the bladder
D. the lobes of the prostate
B. the urothelium, or inner lining of the bladder
Disease process complications
bleeding from friable tumors in the bladder or pain caused by impingement of other organs by the tumor
Treatment related complications
lasting side effects from chemotherapy, such as peripheral neuropathy (a result of damage to the nerves outside of the brain and spinal cord (peripheral nerves), often causes weakness, numbness and pain, usually in your hands and feet), or hemorrhagic cystitis from radiation
Complications from Surgery
bowel obstruction, fistula formation (sores or ulcers), hernia development in the surgical site, and complications/ disadvantages specific to the type of reconstruction of the urinary tract
Assessment and Analysis: Clinical manifestations and what they are associated with
associated with treatment side effects and the emotional factors associated with the diagnosis
- fatigue and poor nutritional intake may be associated with chemotherapy
- antibiotic side effects such as lowered hemoglobin and hematocrit, nausea, and oral thrush
- decreased appetite and a flat affect associated with depression secondary to poor prognosis and a change in body image
- painless hematuria, which may be gross (visual to the eye) or microscopic, is the most common presenting symptom of bladder cancer
- may have irritative voiding symptoms (frequency, urgency, nocturia) which may be due to the presence of a tumor in the bladder
Nursing Diagnoses
- knowledge deficit associated with disease, diagnostics, and management options
- alteration in elimination pattern associated with the effects of treatment on a continuum from irritative symptoms to reconstruction of the urinary tract
Nursing Interventions: Assessments
- vital signs
- urinalysis
Assessments: Vital Signs
- increased pulse and decreased blood pressure may indicate blood loss postoperatively
- increased pulse, decreased blood pressure, and increased temperature may indicate infection
Assessment: Urinalysis
hematuria may be present in bladder cancer
Nursing Actions:
- administer medications as ordered; intravesical immunotherapy, intravesical chemotherapy, immunotherapy, targeted therapy
- continuous bladder irrigation (CBI)
- accurate intake and output
Actions: Administer Intravesical Immunotherapy
immunotherapy is used to aid the body’s natural defense against tumor growth
Actions: administer Intravesical Chemotherapy
chemotherapy is used to destroy the tumor cells
Actions: administer Immunotherapy (systemic)
systemic immunotherapy targets checkpoint molecules to allow for destruction of cancer cells
Actions: Administer Targeted Therapy
target drug therapy is directed at changes in cells that cause them to become cancer or target blood vessels that carry nutrition to the cancer cells
Actions: Continuous Bladder Irrigation (CBI)
CBI may be used after tumor excision or biopsy to clear blood and clots from the bladder and prevent obstruction
Actions: Accurate intake and output
accurate bladder intake and output recording is essential to determine whether clots have cut off the flow of urine,
-if CBI is in place, true urine output= total fluid output minus amount of irrigant instilled
Teaching: bladder cancer, treatment, and outcome
a cancer diagnosis is frightening
-increasing a patient’s knowledge helps him or her feel a measure of control and increases compliance
Well-managed patient
has an effective pain management plan in place, is disease-free or symptom controlled, and is aware of the treatment course and options
- anxiety is at an acceptable level as self-reported or reported by significant others
- there is an awareness of ho to access support through peer and professional groups
