The concept of a multidisciplinary team (MDT) is critically needed in the management of these patients, along with all stages of the disease (from diagnosis to palliative care). The team should at a minimum consist of a urologist, medical oncologist, radiation oncologist, radiologist, pathologist, and eventual ancillary team members.
Dr. Bracarda moved on to discuss the bladder symptoms that arise in patients with advanced disease, who are not candidates for curative treatment. These symptoms include hematuria, dysuria, and pain. Hematuria usually causes clots that result in obstruction and mandate admittance to the hospital due to the complex management of the patient. When the hematuria is intractable, it may be managed with continuous bladder irrigation, selective arterial embolization, palliative radiotherapy, palliative transurethral resection, palliative chemotherapy, or urinary diversion with or without radical cystectomy. When dysuria is significant, the prostate should be assessed as well, including the presence of bladder neck obstruction, and the patient should be assessed for having a low capacity bladder. If symptomatic drug treatments do not help, local treatment needs to be evaluated, whether in the form of transurethral resection, or palliative radiotherapy.
The next topic discussed was the presence of upper urinary tract symptoms. These occur in patients with locally advanced or metastatic bladder cancer with a ureteric obstruction. If hydronephrosis is encountered, it should be treated as soon as possible to relief obstruction with either a nephrostomy tube or a ureteric stent. Relieving the obstruction will cause the pain to reduce significantly. Other reasons to recover and maximize kidney function, is that if at any time point chemotherapy is considered, it may be given immediately. The role of external palliative radiotherapy is still controversial in this setting.
The last topic discussed was various complications occurring in metastatic bladder cancer and their management. The first one discussed was bone or pelvic pain. In these patients, spinal cord compression (SCC) must be suspected and considered. This is an oncological emergency and the most appropriate treatment, whether neurosurgery, radiotherapy or both, should be administered as soon as possible. Next, thromboembolic events were discussed. It is important to differentiate between patients receiving treatment for the localized or locally advanced disease, from those receiving palliative treatments for the advanced metastatic disease. Bladder cancer is a significant risk factor for a thromboembolic event (7.9 events per 100 patient years in metastatic disease). Additional relevant risk factors for a thromboembolic event include a history of a prior thromboembolic event, use of angiogenesis inhibitors, immobilization and hormonal treatment. Cisplatin is also a significant risk factor. To date, there is no supportive evidence to suggest VTE prophylaxis should be given to these patients.
In summary, advanced bladder cancer patients are frequently older with several comorbidities, with a risk of being frail and in need of requiring supportive care only. MDT is an essential part of the management of these patients. Pain in these patients should be diagnosed quickly and managed by appropriate personnel. Palliative care is also a critical part of the MDT team, and they should be easily accessible.
Presented by: Sergio Bracarda, MD, Terni, Itali