of Muscle Invasive Bladder Cancer Dr. Christina Canil Medical Oncologist

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1 Medical Overview and Treatment of Muscle Invasive Bladder Cancer Dr. Christina Canil Medical Oncologist

2 Disclosures Medical Oncologist Urologists/Radiation Oncologists/Radiologists/Pathologists Nursing Radiation therapists/pharmacists/social workers/dieticians

3 Bladder Cancer in Canada th most common cancer in Canada 7,900 Canadians newly diagnosed 80% superficial bladder cancer 20% muscle invasive bladder cancer 2,100 Canadians will die of bladder cancer

4 Risk Factors for Bladder Cancer More common in men and >70 yrs of age Smoking Occupational exposure Chronicinflammation inflammation catheterization, urinary tract infections Cancer treatments radiation, cyclophosphamide p Personal history of bladder cancer Family history of bladder cancer

5 Anatomy of the Urinary Tract

6 Bladder Cancer

7 What is Cancer? Every part of our body is made up of cells that Every part of our body is made up of cells that fit together like building blocks

8 What is Cancer? Cancer is caused when something goes wrong inside the cell. The cells grow out of control and make lots of new abnormal cells

9 What is Cancer?

10 Non Muscle Invasive Bladder Cancer

11 Muscle Invasive Bladder Cancer

12 Muscle Invasive Bladder Cancer

13 Muscle Invasive Bladder Cancer

14 Diagnosis Cancer cells in the urine (voiding cytology) Cystoscopy Biopsy Transurethral Resection of Bladder Tumour (TURBT) Tumour specimen is sent to Pathologist Type of cancer and grade Is it invading into the muscle

15 Types of Bladder Cancer Urothelial carcinoma (transitional cell carcinoma TCC) Squamous cell carcinoma Adenocarcinoma

16 Staging Tests to see if the cancer may have spread anywhere else CT Scan/MRI of the abdomen and pelvis Chest X ray/ct of the chest IVP xray with dye to look at outline of bladder and urinary system Physical examination under anaesthesia

17 Staging (TNM) Stage 0 cancer cell on the surface of the inner lining of bladder (CIS) Stage I tumour has grown deeper in the inner lining of bladder, no muscle involvement Stage II tumour invaded into muscle layer of bladder Stage III tumour has invaded through the muscle wall Stage IV tumour has invaded into nearby organs, spread to lymph nodes, parts of the body far away from the bladder

18 Treatment Options Muscle Invasive Bladder ldd Cancer Size and location of tumour Stage Age and fitness of the patient Any other health problems Patient preference

19 Treatment Options Localized Muscle Invasive Bladder ldd Cancer Surgery Radiation

20 Treatment Options Localized Muscle Surgery Partial Cystectomy Invasive Bladder ldd Cancer Radical Cstectom Cystectomy Males includes removal prostate gland Females includes removal of uterus New system for collecting urine Ileo conduit stoma and bag to collect urine Neo bladder make a new bladder out of piece of intestine

21 Treatment Options Localized Muscle Radiation Invasive Bladder ldd Cancer High energy xray, kills rapidly growing cells External beam radiation Technological advancements to help focus beams on cancer and decrease side effects Up to 6 weeks of treatment Bladder sparing Usually used in combination with chemotherapy

22

23 Radiation Machine

24 Radiation Machine

25 Treatment Options Localized Muscle Invasive Bladder ldd Cancer Side Effects of Radiation Acute Diarrhea Urinary frequency/buring Fatigue Long term Erectile dysfunction Radiation cystitis Chronic change in bowel habits

26 Where does Chemotherapy fit in for the Mx Localized Muscle Invasive Bladder Cancer?

27 Where does Chemotherapy fit in for the Mx Localized Muscle Invasive Bladder Cancer? Without chemotherapy With chemotherapy

28 What is chemotherapy? Medicine that kills cancer cells usually by stopping the cancer cells from growing and dividing Intravenous (needle into the vein) Usually platinum based ddrugs Patients need to be fit We need to assess other health problems

29 What is chemotherapy? Kills rapidly dividing cells including some healthy ones Side effects Fatigue, nausea, weakens immune system (risk for infection), i kidneys, hearing, pins and needles of fingers and feet (damages small nerves)

30 What is the Role of Chemotherapy for localized l dbladder cancer? Combined with Surgery: Usually given before (neoadjuvant) but can be given after surgery (adjuvant) See if chemotherapy is working Shrinks tumour to make surgery easier Kill off any cancer cells that may have escaped from the bladder Improves cure rate

31 What is the Role of Chemotherapy for localized l dbladder cancer? Combined with Radiation: Helps radiation i work better acting as a radiosensitizer Improves local pelvic control rates Given thesame time as radiation

32 Treatment Options Localized Muscle Invasive Bladder ldd Cancer (+/ neoadjuvant chemotherapy) Surgery (+/ adjuvant chemotherapy) Radiation (+/ chemotherapy)

33 Advanced Bladder Cancer Sometimes bladder cancer can spread to other organs (metastases) Spreads through theblood vessels and lymphatics Common sites of metastases: Lungs, liver, bone, brain Not curable but treatable

34 Metastatic Bladder Cancer

35 Treatment of Advanced Bladder Cancer Chemotherapy: Helps patients live longer Improves quality of life Radiation: Helps with pain and bleeding Surgery: Rarely used to remove bladder for pain and bleeding Help with pain or bleeding Supportive Care: Pain medications Oxygen

36 Clinical Trials New ways of treating bladder cancer ce patients ts to improve outcomes In the lab scientists are learning more about what is going on at the molecular level New surgical or radiation techniques New chemotherapy drugs or combinations Personalized medicine

37 Multimodality Therapy Dr. Libni Eapen Study of combining of neoadjuvant and radical cystectomy, followed by adjuvant radiation Proposed to some of the big cooperative groups

38 Take away messages for muscle invasive bladder cancer Bladder cancer that has grown into the muscle layer of the bladder Treatment for localized disease with either: Surgery to remove the bladder +/ chemotherapy Bladder sparing: radiation +(/ ) chemotherapy Multidisciplinary team Chemotherapy h is the main treatment for advanced ddisease Dedication to clinical trials to improve patient care

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