Nursing Considerations for Bladder Cancer Survivorship Care
Bladder cancer is the sixth most common (https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2021.html) cancer in the United States, with an estimated 83,730 adult diagnoses in 2021. Smoking is the greatest risk factor (47% of all cases occur in smokers), followed by advancing age and sex (assigned males are four times more likely to develop bladder cancer than those assigned female). The incidence rate in White people is double that of Black people, but Black people are twice as likely to die from the disease.
The five-year survival rate (https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2021.html) among all patients with bladder cancer is 77%, but that varies with stage of diagnoses. Survival rates are 96% for earlier stages or superficial (in situ) disease, 69% for non–muscle-invasive bladder cancer (NMIBC), and 37% for muscle-invasive bladder cancer (MIBC). Metastatic disease has a 6% five-year relative survival rate, underscoring the need for early diagnosis.
Late and Long-Term Effects
Survivors may be at risk for various late and long-term effects, depending on their treatment modality, specific agents, and dosage. Surgical approaches include transurethral bladder tumor resection for NMIBC, with the addition of partial or radical cystectomy for MIBC. Cystectomy involves the creation of a urinary diversion, which requires long-term care and maintenance of a stoma and the surrounding skin as well as a willingness and ability to self-manage lifelong changes in urinary function.
Intravesical therapy is used in NMIBC to reduce the risk of recurrence or delay disease progression. Treatment is typically bacillus Calmette-Guerin (BCG), but because of ongoing supply shortages, the National Comprehensive Cancer Network recommends (https://www.nccn.org/professionals/physician_gls/pdf/bladder.pdf) that BCG be prioritized for induction of high-risk patients (e.g., high-grade T1 and CIS), with mitomycin and gemcitabine as suggested alternatives.
Adjuvant and neoadjuvant chemotherapy regimens may be either DDMVAC (double-dose methotrexate, vinblastine, doxorubicin, and cisplatin) or cisplatin and gemcitabine. Long-term effects (https://www.ons.org/books/chemotherapy-and-immunotherapy-guidelines-and-recommendations-practice) vary by agent, but cisplatin can cause severe nephrotoxicity, ototoxicity, and peripheral neuropathy. Careful interval assessments and lab review are required, and dose adjustments may be necessary if patients develop any of those toxicities.
Several immune checkpoint inhibitors are approved (https://www.nccn.org/professionals/physician_gls/pdf/bladder.pdf) as second-line therapy for people who cannot receive or who have not responded to platinum-based therapy, including pembrolizumab, avelumab, nivolumab, erdafitinib, and endfortumab vedotin-ejfv. The most common side effects of immune checkpoint inhibitors are acute immune-related adverse events, but Addison disease, arthritis or joint pain, eye-related issues, inflammation of the pituitary gland, and thyroiditis or hypothyroidism have persisted (https://jamanetwork.com/journals/jamaoncology/article-abstract/2777580) for a year or longer.
Ongoing Screening and Prevention
Follow-up care consists (https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf) of monitoring patients for recurrent or progressive disease while also evaluating for psychosocial effects such as fear of recurrence, anxiety, depression, financial difficulties, and physical and sexual functioning. Bladder cancer is the most expensive cancer to treat per capita from diagnosis to death because of extended surveillance, and patients may have significant (https://www.sciencedirect.com/science/article/abs/pii/S1078143920304671?via%3Dihub=) financial implications. Strategies (https://www.sciencedirect.com/science/article/pii/S0749208120301297) to address (https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf) psychosocial concerns include (https://www.sciencedirect.com/science/article/abs/pii/S1078143920304671?via%3Dihub=) support groups, behavior therapy, and referrals to social work, ostomy care services, sexual health, or financial counselors as appropriate.