The chance to participate in developing the EAUN Intravesical instillation in non-muscle invasive bladder cancer guidelines has inspired me since being part of an international group of expert colleagues is a once in a lifetime opportunity!
The EAUN, among its many important roles, is active in the development, implementation, and revision of the guidelines used by nurses who work in urology. A lot of work has been done in recent years to assist colleagues with guidelines distribution and implementation. Among the published guidelines, of particular interest are those about intermittent urethral catheterisation in adults, continent urinary diversion and transrectal ultrasound guided biopsy of the prostate. The majority of these guidelines has also been translated to other languages and is periodically submitted to a rigorous process of revision and update. The guidelines are also available free of charge via the EAUN’s website.
Holistic nursing care
The most recent EAUN guidelines tackled intravesical instillation with mitomycin C and bacillus Calmette-Guérin (BCG) in non-muscle invasive bladder cancer, a topic of debate among nurses, particularly with regards to safety during treatment and patient education. The skills a nurse must possess to manage this procedure extend beyond the clinical setting but also touch on education and social skills since the treatment pathway also includes the guidance of patients during a treatment course that often takes several weeks (with possible repeat procedures).
In the European Union, the age-standardised incidence rate for bladder cancer is 27 per 100,000 for men and six per 100,000 for women (Ferlay et al., 2008a). Bladder cancer incidence has dropped in some registries, possibly reflecting the decreased impact of causative agents, mainly smoking and occupational exposure (Bosetti et al., 2011). Mortality from bladder cancer has also decreased, possibly reflecting an increased standard of care (Ferlay et al., 2008b). Approximately 75% of patients with bladder cancer present with a disease confined to the mucosa (stage Ta, CIS) or submucosa (stage T1). These categories are grouped as non-muscle-invasive bladder tumours.
Non-muscle invasive bladder cancer (NMIBC) has a high prevalence due to low progression rates and long-term survival in many cases (Burger et al., 2013). From the prognostic viewpoint, NMIBC falls into one of three categories: low-risk, intermediate-risk and high-risk for progression and recurrence according to the European Organization for Research and Treatment of Cancer criteria (Babjuk et al., 2013). Based on tumour risk category, the EAU Guidelines recommend a specific intravesical treatment (Babjuk et al., 2013).
The EAUN guidelines aim to provide recommendations on behavioural conduct, evidence-based and shared by experts for an optimal treatment regimen. These recommendations must support the clinical decisions of the professional based on his experience, enabling him to evaluate and personalise the assistance given to the patient, while considering clinical settings and conditions, patient preferences and available resources.
The process of guidelines development began in September 2013, with the creation of the team, coordinated by Susanne Vahr (DK), an expert colleague who has worked on guidelines development, and composed of five other nurses, namely, W. De Blok (NL), B. Thoft Jensen (DK), N. Love-Retinger (US), B. Turner (UK), G. Villa (IT) and urologist Jan Hrbácek (CZ). Each panel member developed a part of the guidelines, which was then shared and discussed with the other members. The final version was then subjected to external blinded review.
The written guidelines are made up of three parts. The first part is methodological and explicitly described the process used for writing guidelines and the definitions of terms. The second and principal part included chapters regarding indications and contraindications to intravesical instillation, and the alternatives to the use of bacillus Calmette-Guérin and mitomycin C. These are followed by chapters on care pathway and safety.
In these chapters, the European Safety Regulation, risk factors and exposure are presented, which are very important for the safety of nurses, healthcare workers, and patients. The succeeding chapter focused on education prior to instillation, followed by the management principles on nursing interventions, including insightful recommendations for treatment management (patient assessment, preparation of intravesical medication, administration, and patient education). The next chapter explained the recommendations regarding complications and side effects of BCG and mitomycin C, how to reduce risk of side effects and manage side effects. The final chapter summarised the literature on patient quality of life.
The third part of the guidelines consists of documents, which help the nurse understand what has to be documented. Aside from examples there is a glossary section with abbreviations and an appendix, including many useful recommendations presented in summary tables and lists, such as a checklist of patient information, management options for side effects (associated with intravesical BCG), examples of training documents, and detailed step-by-step documentation of the procedures for BCG and mitomycin C instillation.
Giulia Villa, RN, EAUN Board member, Milan (IT), firstname.lastname@example.org
European Urology Today Vol. 27 No. 3 June/July 2015