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Case history

image A 77-year-old man presented with a history of painless, visible haematuria to his GP. He was fast-track referred to his local urology team and underwent diagnostic cystoscopy and upper urinary tract imaging. A bladder tumour was diagnosed and biopsied and was staged with a CT scan of the chest, abdomen and pelvis. His case was discussed at the urology multidisciplinary team (MDT) meeting. His disease was confirmed as G3T3N0M0 transitional cell carcinoma of the bladder. Curative surgery or radiotherapy was recommended.

He had a past medical history of tablet-controlled type 2 diabetes mellitus, hypertension and hypercholesterolaemia. Current medications included metformin, simvastatin, amlodipine and ramipril. He was a current smoker with a history of 30 packs/year. He had no family history of cancer. He was retired, having previously worked in the manufacturing of industrial dyes. He was widowed but had close family support. He was independent in basic activities of daily living but required assistance with laundry, shopping and cleaning.

At his oncology appointment, a Comprehensive Geriatric Assessment screening tool identified a history of three falls within the last year. He was referred to the falls clinic for urgent assessment. The falls clinic identified the following contributing factors:

  • Postural hypotension with pre-syncope (BP drop 115/70 mmHg to 95/60 mmHg) secondary to medications.

  • Lower urinary tract symptoms: urgency, frequency and nocturia secondary to bladder cancer, high caffeine intake and detrusor instability. A bladder scan excluded high post-void residual volumes (can occur with anti-muscarinics, obstructing bladder tumours or haematuria-related clots).

  • Environmental factors: low night-time lighting, not wearing glasses and clutter on the bedroom floor were identified by occupational therapy.

  • Fear of falling: identified by physiotherapy resulting in his no longer going out.

The patient discussed his options with the urologist and specialist stoma nurse and underwent cardiopulmonary exercise testing. He opted against radical cystectomy and proceeded with radical radiotherapy.

What was the goal of cancer treatment for this patient?

What could be done to reduce his risk of falls as he underwent cancer treatment?

What is the evidence base for his treatment options?

What factors would affect the decision to deliver chemotherapy?

What factors influence the choice of surgery versus radiotherapy in older patients with muscle-invasive bladder cancer (MIBC)?

What was the goal of cancer treatment for this patient?

The goal of therapy in this patient with MIBC is cure. Potential treatment strategies include radical cystectomy, radiotherapy or concurrent chemoradiotherapy. Approximately 10% of patients have MIBC at diagnosis. The 3 year survival rates for T2 and T3 disease are 50% and 25%, respectively. Treatment counselling should take into consideration the patient's individual goals, independence, estimated longevity and social support to enable a shared medical decision.

What could be done to reduce his risk of falls as he underwent cancer treatment?

Falls are often multifactorial and can be divided into those with and without syncope.1 It is estimated that 30% ...

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