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BCa treatment: Is quality of life sacrificed?

Day two of EAU23 kicked off with a Plenary Session on locally advanced bladder cancer (BCa) and the misconception of informed consent, chaired by Assoc. Prof. Joost Boormans (NL) and Prof. Francisco Cruz (PT). Experts reviewed the quality of life (QoL) of patients with muscle-invasive bladder cancer (MIBC)  treated with radical surgery versus bladder-sparing treatment. The sessions included state-of-the-art lectures, as well as case presentations and discussions on realistic oncological outcomes, functional outcomes and ‘real life’ after surgery for MIBC patients.

In his lecture ‘Psycho-oncological counselling’, psychologist Dr. Christian Schulz-Quach (CA) defined the feelings of embarrassment, shame and anxiety often experienced in BCa patients.

“What I think is really important to you as urologists is a patient’s fear of cancer recurrence (FCR). This is the most common form of cancer-related anxiety after treatment and is defined as fear, worry, or concern relating to the possibility that cancer will come back or progress. This anxiety can be at a level that negatively impacts QoL. For most patients the symptoms do not decrease over time without intervention”. Other forms of patient anxiety he highlighted included scanxiety and survivor’s guilt.

According to Dr. Schulz-Quach, treatment options are available for FCR and psychological interventions based on cognitive behavioural therapy (CBT). Examples of CBT include mindfulness, acceptance and commitment therapy which are efficacious in managing FRC, especially at post-treatment. Some options include contemporary or traditional CBT, emotion-focused psychotherapy and existential psychoanalysis (emotional phenomenology, emotional dwelling).

“Secure early involvement and a common language between the patient, the ward nurses, stoma nurses and primary care”, stated Dr. Bente Thoft Jensen (DK) in her lecture ‘Nurse and stoma therapist’s (hidden) role’. According to her, the stoma nurse is the forefront of the radical cystectomy pathway and she outlined the Urostomy Education Scale (S.A. Kristensen & BT Jensen, WOCON 2013, Jensen et al Urologic Nursing 2013) that is used with nurse-patient stoma education. Multiple aspects of daily life are impacted by urostomy including body imagine, self-esteem, work life, personal care and sexual health, with over 80% of patients reporting a reduced QoL.

“The ability to manage an ostomy appliance independently is the single most important factor for predicting positive psychological adjustment to life with a stoma”. Stoma self-care includes evidence based key skills including: observing the stoma, emptying the pouch, removing the pouch system, cleaning and observing the stoma and the peristomal skin. Hence, stoma prehabilitation is effective and leads to improved stoma self-efficacy, with a positive HRQoL (health-rated quality of life) after stoma-formation.

Incontinence and sexual dysfunction are of real concern especially in young women after neobladder surgery but it is a frequently overlooked topic. “Roughly 25% of new BCa patients each year are diagnosed in female patients” stated Dr. Manuela Tutolo (IT) in her lecture ‘Treatment of incontinence and sexual dysfunction after cystectomy’. “Our goal as urologists’ should be to guarantee optimal urological outcomes together with optimal functional outcomes in these patients. The surgeries are difficult with serious complications that have an impact on QoL”.

According to Dr. Tutolo, there are two types of incontinence after surgery, day time – 10-27% (secondary to ISD [intrinsic sphincteric deficiency]), and nocturnal – 16-57% (overdistention, physiologic diuresis and relaxation of the rhabdosphincter during sleep). This has a marked impact on QoL because the symptoms are mostly severe. “One study showed daytime and nocturnal recovery at one year was 90.9% and 86.4%, but it is a dynamic process.

“Radical cystectomy with ONB (orthotopic neobladder) is an attractive treatment option, but it has high rates of voiding/sexual dysfunction. We should treat patients conservatively as much as possible, but when that is not possible we should be aware that surgeries are difficult and can lead to disastrous results.” In Dr. Tutolo’s opinion, it is important to optimise surgery to preserve sexual function, select patients upfront according to their risks of incontinence or other general complications, and properly inform patients to create realistic expectations. She believes there is a clear need for more prospective studies and a real multidisciplinary approach.

Prof. John Heesakkers (NL) presented a state-of-the-art lecture “Long term follow-up of patients after cystectomy: Functional and vigilance, and the Plenary Session concluded with a game changer: A randomised trial of PHOTOdynamic Surgery in Non-muscle-invasive bladder cancer.

To (re)watch the full presentations, please go to EAU On Demand on the Virtual Platform.