This document provides information about bladder cancer including its definition, types, risk factors, signs and symptoms, staging, diagnostic tests, and treatment options. It defines bladder cancer as uncontrolled growth of cells in the bladder and lists the main types as urothelial carcinoma, squamous cell carcinoma, and flat carcinoma. Risk factors include smoking, chemicals, and chronic infections. Signs may include blood in urine, urinary changes, bone pain, and weight loss. Staging uses TNM criteria and treatments include surgery, chemotherapy, radiation, immunotherapy, and managing side effects.

1. PRESENTED BY:
Mr. Vinay Kumar
M.Sc. Nursing 1st year
HCN.,SRHU
BLADDER
CANCER

2. OBJECTIVES
At the end of the class the student will be able to-
☺Define bladder cancer.
☺Enlist risk factor and causes of bladder cancer.
☺List down the clinical manifestation of bladder cancer.
☺Explain the stages of bladder cancer.
☺Enumerate diagnostic evaluation the bladder cancer.
☺Explain the management of bladder cancer.

4. Urinary bladder
Urinary bladder is smooth
collapsible muscular sac
that store urine temporarily
Location
Just above and behind the
pubic bone

5. Size and shape
• Urinary bladder is around the size
and Shape of pear
• Layers
• The wall contain three layers of
smooth muscle collectively called
detrusor muscle and its mucosa is a
special type of epithelium know as
transitional epithelium

6. Opening
There is three opening
Two is connected with
ureter and one is
connected with urethra

7. Function
The bladder largely serves two functions:
֍Temporary store of urine – The bladder is a hollow organ.
The walls are very distensible, with a folded internal lining
(known as rugae), this allows it to hold up to 600ml.
֍Assists in the expulsion of urine – During voiding, the
musculature of the bladder contracts, and the sphincters relax.

8. DEFINITION
• Bladder cancer is a condition
in which cell in the urinary
bladder start grow
uncontrollably and irregular
shape and have a potential to
spread in the other parts of
body

9. Type of bladder cancer
on the basis of bladder cell
Urothelial or transitional
cell carcinoma
Squamous cell carcinoma
Papillary
Flat carcinoma

10. Urothelial or transitional cell carcinoma
• These are transitional cells
which are able to change the
shape and stretch when the
bladder is full
• These cell present inside lining
of cell
• Most common type of
carcinoma

11. Squamous cell carcinoma
• These cell help in changing the
shape and bladder
• Mainly occur due to prolong on
chronic irritation of bladder and
also due to long term use of
urinary catheterisation.
• These are very rare type of
bladder cancer.

12. Papillary carcinoma
• Cylinder ,finger like projection from
the inner surface toward the hollow
centre of the bladder
• papillary cancer is some times called
papillary urothelial neoplasm of low
malignant potential and tends to have
very good outcomes

13. Flat carcinoma
• Do not grow towards the
hollow parts of the bladder
at all
• if a flat tumour is only in
the inner Layer of bladder
cells

17. Smoking Alcoholism Tabaco chewing

18. Environmental carcinogen
Recurrent / chronic bacterial disease infection bladder stone
Advance age
High urinary ph.
High cholesterol and fatly diet
Pelvic radiation therapy
Cancer of prostate colon and rectum

20. • Haematuria
• Changes in bladder habits-
polyurea
dysuria
burning sensation

21. ꙳Swelling in the feet
꙳Bone pain
꙳Oliguria
꙳Frequent UTI
꙳Being unable to urinate
꙳Lower back pain on affected side
꙳Laws and appetite
꙳Weight loss
꙳Feeling tired or week

22. Staging of bladder cancer

23. It is describe by AJCC (American joint committee on
cancer)TNM system, based on 3 key pieces Of information
♣ T-describe how the main(primary)tumour has growth through
the bladder wall and weather it has grown into near by tissues.
♣ N-indicate any cancer spread to lymph nods near the bladder.
♣ M-indicate if the cancer has spread (metastasized)to distend
sites such as other Orgon.

24. ♣ letters after T, N, and M provide more details about each
of these factors.
♣ Higher numbers mean the cancer is more advanced.
♣ Once a person’s T, N, and M categories have been
determined, usually after surgery, this information is
combined in a process called stage grouping

25. ♣ The earliest stage cancers are called stage 0 and then range
from stages I (1) through IV (4).
♣ As a rule, the lower number means less or no spread cancer.
♣ A higher number, such as stage IV, means a more advanced
cancer.
♣ Staging is based on the results of physical exam, biopsy,
imaging tests, and the results of surgery.

26. stage
0a
0is
Stage grouping
Ta
N0
M0
Tis
N0
M0
Stage description
• Non-invasive papillary carcinoma (Ta).
Grown toward the hollow centre of the bladder
• No spread to nearby lymph nodes (N0)
• No Distant sites (M0).
• Flat, and non-invasive carcinoma and only
Growing in the inner lining layer of the bladder.
• No spread to nearby lymph nodes (N0)
• Distant sites (M0).

27. Stage
I
II
Stage grouping
T1
N0
M0
T2a or T2b
N0
M0
Stage description
• Cancer grown into the layer of connective tissue
of bladder but not reached the muscle layer of
bladder wall (T1).
• No spread to nearby lymph nodes (N0)
• No distant sites (M0).
• Cancer grown into inner (T2a) or outer (T2b) muscle
layer of the bladder wall,
but not passed completely through the muscle of fatty
tissue that surrounds the bladder.
• The cancer has not spread to nearby lymph nodes
(N0)
• No distant sites (M0)

28. stage
IIIa
Stage grouping
T3a, T3b or T4a
N1
M0
stage classification
• Cancer has grown in to the muscle layer and
into the surrounded fatty tissue of bladder (T3a
or T3b).
Might spread into the prostate, uterus, or vagina,
but it is not growing into the pelvic or abdominal
wall (T4a).
• spread to nearby lymph nodes (N1)
• NO to distant sites (M0)

29. Stage
IIIb
Stage grouping
T1-T4a
N2 and N3
M0
stage classification
• Cancer Grow in layer of connective tissue under the
lining of bladder wall (T1)
• grow in connective tissue with muscle layer of
bladder (T2) grown into fatty tissue layer that
surrounds the bladder (T3a or T3b)
• It might have spread in to the prostate, uterus or
vagina but
• not growing in to pelvis or abdominal wall (T4a)
• Spread 2 or more lymph nodes in to pelvis (N2) or
lymph nodes along the common iliac arteries (N3)
• Not spread to distant sites.

30. stage
Iva
IVb
Stage grouping
T4b
N2 and N3
M1
T
N
M
stage classification
Grown through bladder wall into the pelvic or abdominal
wall (T4b)
• Spread 2 or more lymph nodes in to pelvis (N2) or
lymph nodes along the common iliac arteries (N3)
• spread to nearby distant sites.
Might or might not have grown through the wall of
bladder in to near by organ.
It might or might not have spread to nearby lymph nodes.
It has spread to a distant set of lymph nodes. (M1a)
It has spread to 1 or more distant organs.(such as bone,
liver or lungs. (M1b)

33. Diagnostic evaluation
• History collection
PAST HEALTH HISTORY
PRESENT HEALTH HISTORY
• Physical examination
• Urinary analysis- for haematuria
• Urine cytology- to find the cancer cell in urine

34. Urine test for tumour marker
Newer test look for substances in the urine that might indicate
bladder cancer.
These include-
Urovision – these show chromosomal changes in bladder cell.
BTA Test – These tests look for a substances called bladder tumour
–associated antigen (BTA) also known as CFHrp, in the urine.

35. • Immunocyte – This tests look at cells in the urine for the
presence of substances such as mucin and carcinoma
embryonic antigen (CEA)
• NMP22 Bladder check – this tests looks for a protein called
NM22 in the urine.
• Cystoscope – It is the key diagnostic procedure for bladder
cancer.
It allow to see inside the body with a thin, lighted, flexible tube
called cystoscope.

37. PET SCAN

38. Ultrasonography

40. Most common treatment options for bladder cancer are listed
below,
Treatment options and recommendations depend on several
factors, including:
• Type, stage, and grade
• Possible side effects
• The patient’s preferences and overall health

41. Intravesical (local)chemotherapy.
Drugs delivered into the bladder through a catheter
Local treatment only destroys superficial tumour cells that come in
contact with the chemotherapy solution.
Not for metastasis condition.
Mitomycin (Mitozytrex, Mutamycin) and thiotepa are the drugs used
most often for intravesical.
Systemic chemotherapy.

43.  Combination of methotrexate, vinblastine, Adriamycin, and
cisplatin, for metastatic bladder cancer.
 Gemcitabine plus cisplatin is now considered a 1st line treatment
for bladder cancer.
Fluorouracil (Adrocil)- Antimetabolite drugs which inhibit the
RNA synthesis
Methotrexate- Inhibit both RNA or DNA synthesis.

44. Gemcitabine- it inhibit the DNA replication.
Antineoplastic, vinca alkaloid-it act on the G phase of mitosis,
inhibiting the DNA and RNA synthesis. E.g. vinblastine
Anthracycline- it synthesis by steric obstruction.
They intercalate between DNA base pairs and triggers DNA
cleavage by topoisomerase 2nd . E.g. doxorubicin, valrubicin

45. Alkylating agent- Inhibit the cell growth and proliferation.
They inhibit the DNA synthesis by proliferation of DNA cross link.
e.g. cisplatin, carboplatin
PD-1/ PD-L1 inhibitors- these is expressed on the surface of activated
T cell under normal condition.
PD-L1 interaction inhibit immune activation and reduce T cell
cytotoxic activity when bound. E.g.- Atezolizumab, Nivolumab

46. Surgical management

47. Transurethral bladder tumour resection (TURBT).
Used for diagnosis, staging, as well as
treatment.
Anaesthetic is given to block the
awareness of pain.
Inserts a cystoscope through the urethra
into the bladder.
Then removes the tumour using a tool
with a small wire loop, a laser, or
fulguration (high-energy electricity).

48. Cystectomy
Removal of the whole bladder and possibly nearby tissues and
organs.
For men, the prostate and urethra also may be removed.
For women, the uterus, fallopian tubes, ovaries, and part of the
vagina may be removed.
In addition, lymph nodes in the pelvis are removed for both men
and women. This is called a pelvic lymph node dissection.

49. Urinary diversion. If the bladder is removed, create a new way
to pass urine out of the body.
 One way is,use a section of the small intestine or colon to
divert urine to a stoma or ostomy (opening) on the outside of
the body.
• Then patient wear a bag that attached to the stoma to collect
and drain urine.
• Increasingly, use the part of the small or large intestine to
make a urinary reservoir, which is a storage pouch that sits
inside the body.
• Then pouch is connect to the urethra that is called neobladder.

50. Urinary diversion

51.  2nd way is, to use an internal (inside the abdomen)
pouch made of small intestine is created and connected
to the skin on the abdomen or umbilicus (belly button)
through a small stoma.
In this patients do not need to wear a bag.
Patients drain the internal pouch multiple times a day by
inserting a catheter through the small stoma and
immediately removing the catheter.

53. • Also called biologic therapy, designed to
boost the body’s natural defences to fight the
cancer.
• It is made either by the body or in a
laboratory to improve, target, or restore
immune system function.

54. Bacillus Calmette-Guerin (BCG),
Standard immunotherapy drug similar to the
bacteria that causes tuberculosis.
֍ Placed directly into the bladder through a
catheter (intravesical therapy).
֍ That stimulates the immune system to
destroy the tumour.
BCG can cause flu-like symptoms, chills,
mild fever, fatigue, a burning sensation in
the bladder, and bleeding from the bladder.

55. Interferon
(Roferon-A, Intron A, Alferon) is
another type of immunotherapy that
can be given as intravesical therapy.
Sometimes combined with BCG if
using BCG alone does not help treat
the cancer

56. ☺Immunotherapy block a protein called PD-1.
☺ PD-1 is found on the surface of T-cells, which are a
type of white blood cell that directly helps the body’s
immune system fight disease.
☺Because PD-1 keeps the immune system from
destroying cancer cells,
☺ stopping PD-1 from working allows the immune
system to better eliminate the disease.

59. ♣ Use of high-energy x-rays or other particles to destroy
cancer cells.
♣ Radiation therapy is usually not used by itself as a primary
treatment for bladder cancer, but it may be given in
combination with chemotherapy.

60. Types of radiation therapy
1. External beam radiation therapy
2. internal radiation therapy or brachytherapy.

61. External beamradiation therapy
• Common type of radiation
treatment is called external-beam
radiation therapy, given from a
machine outside the body.
• Machine is called linear
accelerator

62. Internal radiation therapy
• Radiation therapy is given using
implants, it is called internal
radiation therapy or brachytherapy.
• In this a radioactive seed is inserted
in bladder(radioisotope like cobalt-
60)

64. Major side effects are-
• Anaemia
• Thrombocytopenia
• Constipation
• Diarrhoea
• Fertility issue in both male and female
• Alopecia
• Peripheral neuropathy
• Sexual health issue in both men and women
• Urinary and bladder problem.

65. Care for side effects
• Stop the chemotherapy and consult the physicians.
• Take the concern before continue the treatment
• Palliative care or supportive care

67. Assessment
♣ Pain
♣ Anxiety
♣ Impaired urinary elimination
♣ Ineffective coping mechanism
♣ Sexual disfunction
♣ Disturbed body image

68. Nursing diagnosis
Acute pain related to disease process as evidence by patient
verbalization
Goal- to control pain
Intervention-
• Assess the location, intensity duration of pain.
• Encourage to maintain bed rest.
• Administer the prescribed medication (analgesic)

69. Impaired urinary elimination related to bladder cancer as
evidence by patient verbalization
Goal- to maintain the urinary elimination pattern
Intervention
• Observe the amount, colour, and frequency of urination
• Administer the prescribed medication
• Educate the eliminate regarding disease process

70. Anxiety related to disease process and haematuria as
evidence by patients query regarding disease process.
Goal- to minimize the anxiety of patient
Intervention
• Assess the patient general condition
• Check the patient knowledge level regarding disease level
• Listen the patient carefully
• Educate patient regarding disease condition