- 7th most common cancer in the UK.
- Male:female ratio 3-4:1
- In 2011 5081 people died of bladder ca
- Peak incidence > 60 year-olds
Risk factors
- Increasing age
- Smoking
- Exposure to industrial chemicals
Symptoms:
Visible or non-visible blood in the urine
75-80% of bladder ca are non-muscle invasive
Diagnosing and staging bladder cancer
Diagnosis:
- CT/MRI staging before TURBT if MIBC is suspected at cystoscopy.
- Offer white-light TURBT + one of (1-phtodynamic diagnosis, 2- narrow-band imaging, cytology or a urinary biomarker test (UroVysion using (FISH), ImmunoCyt or NMP22)
- Offer a single dose of intravesical mitomycin C given at the same time as the first TURBT
Non-muscle-invasive-bladder-cancer (NMIBC)
Prognostic markers and risk classification
Important factors to consider:
- Recurrence history
- Size and number of cancers
- Histological type, grade, stage and presence (or absence) of flat urothelium, detrusor muscle (muscularis propria), and carcinoma in situ
- The risk category
- Predicted risk of recurrence and progression (using a risk prediction tool)
High risk NMIBC
Offer BCG or radical cystectomy
discussion with the patient should include
- Type, stage, grade of cancer
- Presence of CIS
- Presence of variant pathology
- Prostatic urethra or bladder neck status
- Number of tumours
- Risk of progression to muscle invasion, metastases and death
- Risk of understaging
- Benefits of both treatments, including survival rates and likelihood of further treatment
- Risks of both treatments
- Comorbidities and life expectancy
- Impact on QOL, body image, sexual and urinary function
Follow up for NMIBC
Low risk
Discharge if no recurrence within 12 months
Intermediate-risk NMIBC
Cystoscopic follow-up at 3,9 and 18 months, and once a year thereafter.
Treating MIBC
Neoadjuvant chemotherapy for newly diagnosed MIBC
Offer neoadjuvant chemotherapy using a cisplatin combination regimen before radical cystectomy (RC) or Rx
Radical therapy for MIBC
Offer RC or Rx
Staging
- Further TURBT within 6 weeks if no detrusor muscle present
- CT/MRI for MIBC, High risk NMIBC assessed for radical treatment
- Consider CT Urography for people with new or recurrent high-risk NMIBC or MIBC to check upper tracts
- Consider CT thorax for people with MIBC
- Consider FDG-PET scan if there are indeterminate findings on CT/MRI or high risk for metastases (T3b disease)
Treating NMIBC
Risk classification in NMIBC
Treatment:
Intermediate risk NMIBC
- Offer 6 doses of intravesical Mitomycin C
- If recurs refer to MDT
High risk NMIBC
- Offer another TURBT ASAP no later than 6 weeks after 1st resection
- Offer the choice of BCG or RC
BCG:
- Offer induction and maintenance
- If induction fails refer to MDT
- MDT should assess suitability of RC, or further intravesical therapy (if RC is unsuitable or declined or if the recurrence intermediate or low-risk)
Recurrent NMIBC
Consider fulguration without biopsy if
- No previous intermediate or high risk history
- Disease free interval of at least 6 months
- Solitary papillary recurrence
- Tumour diameter of 3 mm or less
Managing side effects of treatment
- Don't offer prophylaxis before BCG
- Seek MDT advice if antispasmodics or non-opiate analgesia are not controlling bladder toxicity post BCG and cystoscopy is normal.
Follow-up NMIBC
Low-risk NMIBC
- Offer cystoscopy at 3 and 12 mo
- Dont use urinary biomarkers or cytology
- Discharge to primary care if no recurrence within 12 mo
Intermediate risk NMIBC
- Offer cystoscopy at 3,6,9, and 18 mo and once a year thereafter
- Discharge to primary care after 5 yrs of f/u if disease free
High risk NMIBC
- cystoscopy every 3 mo for the first 2 yrs then every 6 mo for the next 2 yrs then once a yr thereafter
Treating MIBC
Neoadjuvant chemotherapy
Offer it (cisplatin based)
Radical therapy
RC or Rx
RC
Offer stoma or continent diversion (neo bladder or catheterisable reservoir)
Contraindications to continent diversion
- cognitive impairment
- impaired renal function
- significant bowel disease
Offer opportunity to have discussions with a stoma care nurse
Adjuvant chemotherapy after RC for MIBC or LN(+) bladder ca
Consider adjuvant cisplatin combination chemo after RC for people with diagnosis of
MIBC
LN (+) BC
for whom neoadjuvant chemo was not suitable
- muscle invasion was not shown on pre-cystectomy biopsies
Radical Rx
- Use a radiosensitiser (mitomycin + fluorouracil [5-FU])
- 64 Gy in 32 fractions over 6.5 weeks
- 55 Gy in 20 fractions over 4 weeks
Follow up after treatment for MIBC
After RC
- Annual imaging of upper tracts for HN, stones and cancer and (GFR)
- CT C/A/P at 6,12 and 24 mo after RC
- Annual monitoring of metabolic acidosis and B12 and folate deficiency
- For men with a defunctioned urethra, urethral washing for cytology and/or urethroscopy annually for 5 years.
After radical Rx
- Rigid cystoscopy 3 mo after completion of Rx followed by rigid or flexi
- Every 3 mo for hte first 2 yrs then
- Every 6 mo for hte next 2 yrs then
- Every yr thereafter
- Upper tract imaging every year for 5 years
- CT C/A/P 6,12,24 mo after Rx
Managing locally advanced or metastatic MIBC
First-line chemotherapy
- Offer a cisplatin-based chemotherapy (cisplatin + gemcitabine, or MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) in combination with G-CSF (granulocyte-colony stimulating factor) if
- ECOG performance status of 0 or 1
- eGFR of 60 or more
- Offer carboplatin + gemcitabine to people with ECOG 0-2 if cisplatin is unsuitable because
- ECOG >=2
- GFR <60
- Comorbidity
Second-line chemo
- Gemcitabine + cisplatin or accelerated high dose MVAC + G-CSF if progression after 1st line chemo if
- GFR >=60
- ECOG 0-1
Consider 2nd line chemo with carboplatin + paclitaxel or gemcitabine + paclitaxel if cisplatin based chemo is not suitable.
Managing symptoms of locally advanced or metastatic bladder cancer
Bladder symptoms
- Offer palliative hypofractionated Rx for haematuria, dysuria, frequency or nocturia
Loin pain and symptoms of renal failure
- Discuss
- prognosis
- advantages and disadvantages of Tx options including best supportive care
- Consider percutaneous nephrostomy or retrograde stenting to
- Relieve pain
- Treat AKI
- Improve renal function before further treatment
Intractable bleeding
- Consider hypofractionated Rx or embolisation
Pelvic pain
- Consider in addition to best supportive care
- hypofractionated Rx if no previous Rx to pelvis
- Nerve block
- Palliative chemotherapy
Specialist palliative care for people with incurable bladder cancer
- Refer to urology MDT
- Tell the primary care team within 24hrs
- A member of the urology MDT should discuss prognosis and management with pt
- Discuss palliative care services
