Bladder cancer is a common disease in the UK, affecting more than 12,500 individuals each year and causing 5000 deaths1. It is the most frequently occurring cancer of the urinary system and accounts for 1 in 20 new cases of cancer each year in the UK.
Bladder cancer is more common in men than women with a worldwide male: female ration of 3:1.
About 80% of bladder tumors are confined to the bladder mucosa and called superficial tumors. About 20% are muscle-invading tumors2.
Bladder tumors may be single or multiple and can occur anywhere in the urothelium but are usually found on the posterior and lateral wall of the bladder especially near the ureteric orifices. They may also be found in the renal pelvis, ureters and urethra3.
The most common symptom of bladder cancer in approx. 85-90% is painless and intermittent haematuria. Investigation is always necessary, as other causes may be to blame. Other symptoms of bladder cancer include, frequent micturition, dysuria, urgency of micturition.
Pain, particularly in the suprapubic region, perineum or sacrum is associated with advanced disease. Loin pain may be an indication of ureteric obstruction.
Patients who present with haematuria undergo a number of investigations, which may include all or some of the following:
· mid stream urine sample
· urine cytology
· Full blood count
· Urea & Electrolytes
· Ultrasound of kidneys & bladder
· Intravenous Urogram
Staging of the tumor is essential for appropriate treatment.
Picture supplied by KYOWA.
An accurate assessment of the tumour including depth of penetration into the bladder, involvement of lymph nodes, and spread to other organs are done using the internationally agreed TNM system4.
The pathological grading of tumors, which is based on the degree of anaplasia, is also assessed using the WHO 1973 classification.
· G1 – well differentiated
· G2 – moderately differentiated
· G3 – poorly differentiated
The stage of the tumour is an important prognostic factor. Superficial tumors have the best prognosis with 90-95% of patients alive, 5yrs from diagnosis5. Patients with muscle invasive tumour have a poorer prognosis.
Bladder cancer spreads by direct invasion through the bladder wall into adjacent organs. Spread can also occur via the lymphatic system with the pelvic and para-aortic nodes involved leading to circulatory involvement giving rise to metastases in the lungs, liver and bones.
Intravesical chemotherapy is administered to patients diagnosed with carcinoma of the bladder. The principle behind the treatment is to expose the bladder mucosa to a chemotheraputic agent; thus killing as many malignant cells as possible, but minimising damage to the normal mucosa. It will also reduce the risk of recurrence.
The safe administration of cytotoxic drugs.
1.3 Patient/client group
Patients with a diagnosis of bladder cancer under the direct care of a Consultant Urologist.
1.4 Exceptions/ contraindications
This policy does not cover the administration of chemotherapy by any other routes.
Bladder chemotherapy should only be administered in designated areas: DDU until the service is relocated, Pembroke Unit, Downton Ward, Idmiston Ward, Bishopstone Ward & Day Surgery Theatres only.
When chemotherapy should be administered
Bladder chemotherapy should only be administered during the "normal working hours" of the Urology Nurse Specialists.
The only exception being when surgery has taken place on a Friday and chemotherapy needs to be administered 24hrs post-op at a weekend. In this instance a minimum of one Urology chemotherapy-trained nurse should be on duty to ensure safe administration and close monitoring takes place.
This policy covers the administration of Mitomycin C chemotherapy and BCG Immunotherapy.
Mitomycin C is administered within 24 hours of bladder tumour resection as a single dose then once a week for 6 weeks. The patient will then have follow up cystoscopies, if further bladder chemotherapy is required the patient will be referred back to the service.
BCG Immunotherapy commences 2 weeks post surgery to prevent any systemic involvement. BCG is administered once a week for 6 weeks. The patient will then have a Cystoscopy approximately 3 months following treatment. The BCG is then administered at 3 months, 6 months, 9 months and 12 months as "top up immunisation". After this time the patient is put on maintenance therapy which is tapered to the individual.
Consultant Urologists or a Staff Grade Urologist should prescribe the first dose of bladder chemotherapy on an appropriate chemotherapy chart. Other trained medical staff can prescribe all subsequent doses (See Operational Policy for Chemotherapy within Oncology/Haematology). Pre printed prescriptions will be developed in the near future as the service develops.
Written consent must be sought from the patient before bladder chemotherapy can be administered.
Consent form 3 is to be used where the procedure does not involve any impairment of consciousness.
(See Policy for Consent to Examination or Treatment)
Transportation and Storage
An authorised member of the nursing team collects the bladder chemotherapy from the pharmacy department. Each chemotherapy drug is labeled with specific information on its storage until it is administered. Drugs that require refrigeration must be stored in a separate cytotoxic drug fridge that is lockable.