Bladder Cancer Awareness

Transcript

00:00 --> 00:02Support for Yale Cancer Answers comes
00:02 --> 00:05from AstraZeneca, focused on exploring
00:05 --> 00:07innovative treatment approaches for
00:07 --> 00:10people living with bladder cancer.
00:10 --> 00:14Learn more at astrazeneca-us.com.
00:14 --> 00:15Welcome to Yale Cancer
00:15 --> 00:17Answers with your host
00:17 --> 00:18Doctor Anees Chagpar.
00:18 --> 00:20Yale Cancer Answers features the
00:20 --> 00:22latest information on cancer care by
00:22 --> 00:24welcoming oncologists and specialists
00:24 --> 00:26who are on the forefront of the
00:26 --> 00:28battle to fight cancer. This week,
00:28 --> 00:30it's a conversation about the diagnosis
00:30 --> 00:32and treatment of bladder cancer,
00:32 --> 00:33with doctor John Colberg.
00:33 --> 00:35Doctor Colberg is a professor of
00:35 --> 00:37urology and director of Urologic
00:37 --> 00:39Oncology at the Yale School of
00:39 --> 00:41Medicine where Doctor Chagpar is
00:41 --> 00:44a professor of surgical oncology.
00:44 --> 00:47Maybe we can start off by talking
00:47 --> 00:50a little bit more about bladder cancer.
00:50 --> 00:52It certainly isn't one of the most
00:52 --> 00:54common cancers that we think about.
00:54 --> 00:57So tell us a little bit more about it.
00:57 --> 01:00How common is it? Who gets it, and
01:00 --> 01:01how deadly is it?
01:02 --> 01:05If you look at non skin cancer cancers,
01:05 --> 01:08it's the fifth most common
01:08 --> 01:10cancer that we diagnose.
01:10 --> 01:13It's the fourth most common in males.
01:13 --> 01:17About 80,000 cases are diagnosed a year.
01:17 --> 01:20The vast majority are male,
01:20 --> 01:24about 62,000 versus 19,000 for women and
01:24 --> 01:29the average age of diagnosis is 73.
01:29 --> 01:32The chance of a man getting bladder
01:32 --> 01:35cancer is about one out of 27 and
01:35 --> 01:37for women about one out of 80.
01:39 --> 01:42So when you think about it,
01:42 --> 01:45being in the top five,
01:45 --> 01:47it actually might be more common
01:47 --> 01:48than many people realize.
01:48 --> 01:51So what are the risk factors?
01:51 --> 01:53Are there modifiable things that
01:53 --> 01:55people should be thinking about that
01:55 --> 01:57may predispose to bladder cancer?
01:57 --> 02:00Absolutely, I think the biggest
02:00 --> 02:02one is cigarette smoking.
02:02 --> 02:05A cigarette smoker has a three times greater
02:05 --> 02:08chance of developing bladder cancer.
02:08 --> 02:10There's some environmental and
02:10 --> 02:12workplace exposures that you
02:12 --> 02:16might want to think about which
02:16 --> 02:18includes people who
02:18 --> 02:21work in textiles,
02:21 --> 02:26maybe professions of painters, truck drivers.
02:26 --> 02:28And on top of that,
02:28 --> 02:30a lot of these people also smoke,
02:30 --> 02:33so they have a much higher risk
02:33 --> 02:34of developing bladder cancer.
02:34 --> 02:36Now there's no predisposing
02:36 --> 02:38genetic factors perse.
02:38 --> 02:40Most of them are related to being
02:40 --> 02:42turned on by cigarette smoking
02:42 --> 02:44or environmental exposures.
02:45 --> 02:47tI hink with the cigarette smoking
02:47 --> 02:50and I'd like to come back to
02:50 --> 02:52that in terms of cumulative risk
02:52 --> 02:54and whether quitting smoking
02:54 --> 02:57actually reduces your risk, but
02:57 --> 02:59in terms of workplace exposures,
02:59 --> 03:01oftentimes if you're a
03:01 --> 03:03painter or a truck driver,
03:03 --> 03:05that's your livelihood.
03:05 --> 03:08Are there things that people are
03:08 --> 03:10doing to reduce some of the exposures
03:10 --> 03:13that people get to various chemicals
03:13 --> 03:15associated with these occupations?
03:15 --> 03:16So, for example,
03:16 --> 03:19are there governmental bans
03:19 --> 03:22on some of these chemicals that may be
03:22 --> 03:25found in paints and dyes and so on?
03:29 --> 03:31There's a fairly delayed response to
03:31 --> 03:33getting the cancer after this exposure,
03:33 --> 03:37so a lot of these men and women we see
03:37 --> 03:40have been exposed 20 or 30 years ago or
03:40 --> 03:4340 years ago when there weren't a lot
03:43 --> 03:46of restrictions and new laws in place
03:46 --> 03:48to prevent from limiting their exposure.
03:48 --> 03:51But some of them,
03:51 --> 03:53truck drivers are exposed to diesel fuel
03:53 --> 03:56or people work in the dry cleaning business
03:56 --> 04:00are exposed
04:00 --> 04:03so I think that we are
04:03 --> 04:06more aware of the exposures now and
04:06 --> 04:08certainly with cigarette smoking
04:08 --> 04:10it's pretty easy to say,
04:10 --> 04:11stop smoking.
04:11 --> 04:14And sadly though there
04:14 --> 04:16really is no legal restrictions on
04:16 --> 04:19smoking and so it really is up to
04:19 --> 04:21people to take control of their own
04:21 --> 04:23health with regards to cigarette
04:23 --> 04:25smoking though one of the questions
04:25 --> 04:28that often comes up is
04:28 --> 04:30people who have engaged in smoking
04:30 --> 04:32often find it very difficult
04:32 --> 04:35to quit and so they say,
04:35 --> 04:37if I've already been smoking
04:37 --> 04:39for 10, 15, 20 years,
04:39 --> 04:41the damage is already done,
04:42 --> 04:44so why bother quitting smoking?
04:44 --> 04:47Is the risk of bladder cancer cumulative?
04:47 --> 04:48In other words,
04:48 --> 04:51you keep adding to that risk
04:51 --> 04:55the more you smoke and after a certain point,
04:55 --> 04:58if you say quit for five or ten years,
04:58 --> 05:00your risk goes back down.
05:00 --> 05:03Or is it that
05:03 --> 05:04cigarette smoking causes damage
05:04 --> 05:06that once it's done is done,
05:06 --> 05:10and even if you quit smoking at that point,
05:10 --> 05:12you're still at risk of
05:12 --> 05:13developing bladder cancer.
05:13 --> 05:15I don't think we know
05:15 --> 05:17that for certain, but
05:17 --> 05:20certainly patients who stop smoking,
05:20 --> 05:22I think the recurrence of the
05:22 --> 05:24bladder cancer goes down.
05:24 --> 05:26So I think that even though it
05:26 --> 05:28may not completely absolve them
05:28 --> 05:30from getting more bladder cancer,
05:30 --> 05:32it certainly will help them.
05:34 --> 05:36And so the other thing that's interesting
05:36 --> 05:40is that you mentioned that there was this
05:40 --> 05:42gender difference in terms
05:42 --> 05:44of bladder cancer, with more men
05:44 --> 05:46getting bladder cancer than women,
05:46 --> 05:48I wonder whether that's related
05:48 --> 05:49to differences in smoking.
05:49 --> 05:52And now that we are beginning to
05:52 --> 05:54see more and more women smoking,
05:54 --> 05:55whether they've seen anything
05:55 --> 05:58change in terms of the risk of
05:58 --> 06:00women developing bladder cancers.
06:01 --> 06:02I think that's a reasonable supposition.
06:02 --> 06:06We don't see that yet, but I think that
06:06 --> 06:08like other types of cancer that may take
06:08 --> 06:10several years to kind of catch up.
06:11 --> 06:14The other question we've seen in
06:14 --> 06:18other cancers is there a synergistic
06:18 --> 06:20effect between alcohol and
06:20 --> 06:23smoking in terms of cancer risks.
06:23 --> 06:26Do we see that in bladder cancer too
06:26 --> 06:31or is it really the environmental and
06:31 --> 06:34occupational exposures instead of alcohol?
06:34 --> 06:36I don't think we've
06:36 --> 06:40seen that with alcohol and bladder cancer.
06:43 --> 06:47Is the risk higher with people who have an
06:47 --> 06:50occupational risk like
06:50 --> 06:52being exposed to various chemicals in
06:52 --> 06:55the workplace if they are also smokers,
06:55 --> 06:57is that just additive,
06:57 --> 06:59but a synergistic risk?
06:59 --> 07:05Or is it
07:05 --> 07:06an additive risk?
07:06 --> 07:08I don't think we know for certain,
07:08 --> 07:10but I think that anecdotally
07:10 --> 07:11it's synergy.
07:11 --> 07:13So typically the worst
07:13 --> 07:15cancers we see tend to be
07:15 --> 07:17in people who have environmental
07:17 --> 07:20exposures and they smoke.
07:20 --> 07:24And so do we ever see bladder cancer
07:24 --> 07:28in people who don't have one of those
07:28 --> 07:30two risk factors?
07:31 --> 07:33Yes, absolutely.
07:33 --> 07:35Are these risk different than others in terms
07:35 --> 07:37of how they look biologically?
07:37 --> 07:40How they behave, and so on.
07:40 --> 07:43I don't think we know that for certain,
07:43 --> 07:46but again, not everybody
07:46 --> 07:48that smokes gets bladder cancer.
07:48 --> 07:50And some people
07:50 --> 07:53get bladder cancer, who
07:53 --> 07:54don't smoke.
07:54 --> 07:56But I guess the definitive message is
07:56 --> 07:59if you smoke you are at greater
07:59 --> 08:01risk of getting bladder cancer
08:01 --> 08:04and so doing what you can to quit
08:04 --> 08:07smoking may help you either to
08:07 --> 08:09avoid getting bladder cancer to
08:09 --> 08:12begin with and reducing your risk
08:12 --> 08:14of getting a recurrence.
08:14 --> 08:17So let's talk a little bit about bladder
08:17 --> 08:21cancer in terms of how it presents.
08:21 --> 08:23How do people actually
08:23 --> 08:25develop bladder cancer?
08:25 --> 08:26What symptoms does that
08:26 --> 08:28present with, typically?
08:28 --> 08:30Do people with bladder cancer
08:30 --> 08:33present with blood in the urine?
08:38 --> 08:40Or is it found when he look under
08:40 --> 08:42the microscope?
08:47 --> 08:49So two questions there.
08:49 --> 08:50The first question is,
08:50 --> 08:51sometimes when people
08:51 --> 08:53find blood in their urine,
08:53 --> 08:56they assume that that's something like
08:56 --> 08:59a kidney stone or something like that.
08:59 --> 09:00How do you differentiate that
09:00 --> 09:03from a bladder cancer and how do
09:03 --> 09:04you actually find microscopic
09:04 --> 09:06material that you can't really see?
09:06 --> 09:08Is that something that would then
09:08 --> 09:10cause people to present very late?
09:10 --> 09:12How is that picked up?
09:12 --> 09:18I think that if you have symptoms,
09:18 --> 09:25maybe even infection or pain with urination,
09:25 --> 09:27pattern changes, some people will
09:27 --> 09:31look at your analysis and see if
09:31 --> 09:33there's microscopic hematuria
09:33 --> 09:37and that's one way that we find a lot of
09:37 --> 09:40people just present with blood and
09:40 --> 09:42that's how they initially present,
09:42 --> 09:46and so in either of those two circumstances,
09:46 --> 09:49either you have symptoms of an infection
09:49 --> 09:52or pain, or frequency of going,
09:52 --> 09:56or you actually see blood in your urine, you
09:56 --> 10:00go to your family doctor and they do a
10:00 --> 10:02test and they find blood in your urine.
10:02 --> 10:03What's the next step?
10:03 --> 10:05The first thing you want
10:05 --> 10:06to look at is
10:06 --> 10:09do they have symptoms of an infection?
10:09 --> 10:11So if they have symptoms of infection,
10:11 --> 10:14they need to treat the infection and the blood
10:14 --> 10:17should go away, if it doesn't go
10:17 --> 10:19away or the symptoms don't
10:19 --> 10:22get better after treating infection
10:22 --> 10:24then you need what we call the
10:24 --> 10:27work up of the blood in the urine
10:27 --> 10:29and that work up usually entails
10:29 --> 10:32some type of an X Ray study like a CT
10:32 --> 10:35scan or an MRI because you can bleed
10:35 --> 10:38from any part of the urinary tract,
10:38 --> 10:40the lining of the kidneys, the kidney itself,
10:44 --> 10:45the bladder itself,
10:45 --> 10:47so you want to image or
10:47 --> 10:49look at the kidneys
10:49 --> 10:52with the CT scan
10:52 --> 10:55and then
10:55 --> 10:57you also want to look into the bladder,
10:57 --> 10:59and that's usually an office procedure
10:59 --> 11:01where you take a small telescope
11:01 --> 11:04with the light at the end of it and
11:04 --> 11:06actually look into the bladder and can
11:06 --> 11:08visualize the lining of the bladder.
11:10 --> 11:14And so if you do that,
11:14 --> 11:17people often ask what does
11:17 --> 11:20cancer look like? Will you see
11:20 --> 11:22in the bladder the tumor growth?
11:24 --> 11:26You'll actually see it emanating
11:26 --> 11:27from the bladder wall.
11:27 --> 11:30It may look a little like cauliflower
11:30 --> 11:33or papillary
11:33 --> 11:34growth in the bladder,
11:34 --> 11:36or it could be something as subtle
11:36 --> 11:39as a redness in the bladder,
11:39 --> 11:43or could be a solid mass in the bladder.
11:43 --> 11:47So all those are related to
11:47 --> 11:50what that looks like under the
11:50 --> 11:52microscope once you take that out,
11:52 --> 11:54because lower grade tumors
11:54 --> 11:56tend to be more papillary,
11:56 --> 11:58meaning they're not as aggressive in
11:58 --> 12:00higher grade tumors tend to be more solid.
12:01 --> 12:02So how do
12:02 --> 12:05you exactly take out this cancer
12:05 --> 12:07in order to find out under the
12:07 --> 12:09microscope what it looks like?
12:09 --> 12:12That sounds like a biopsy to me.
12:12 --> 12:16So how exactly is that done?
12:16 --> 12:19We usually schedule the person
12:19 --> 12:23in the operating room
12:23 --> 12:26with the anesthesia so that you
12:28 --> 12:30go in with a telescope, a little
12:30 --> 12:32bigger telescope and
12:32 --> 12:35through that telescope we're able
12:35 --> 12:37to trim or cut the tissue out.
12:37 --> 12:39Usually we could remove
12:39 --> 12:42all the tumor itself,
12:42 --> 12:45and then we take that tissue
12:45 --> 12:46to pathology so they
12:46 --> 12:49can analyze it.
12:49 --> 12:50It sounds like that's a little operation,
12:50 --> 12:52not a big operation because
12:52 --> 12:54you're still using a telescope.
12:54 --> 12:56It doesn't sound like this is
12:56 --> 12:59a big cut in the abdomen and
12:59 --> 13:00you're removing the bladder.
13:00 --> 13:02It sounds minimally
13:02 --> 13:04invasive. Is that right?
13:06 --> 13:09Yes, oftentimes it's done as an outpatient.
13:09 --> 13:10Occasionally the patient will require
13:10 --> 13:13a tube in the bladder overnight,
13:13 --> 13:16or for a couple days, depending on how
13:16 --> 13:19much you have to do, but the real
13:19 --> 13:22risks of the procedure is bleeding,
13:22 --> 13:25because obviously you're cutting tissue,
13:25 --> 13:28but you're able to also
13:28 --> 13:30cauterize the area. Rarely
13:30 --> 13:33opening the bladder can
13:33 --> 13:35perforate the bladder,
13:35 --> 13:37but those are very uncommon.
13:38 --> 13:41Well, we're going to pick up right after
13:41 --> 13:43we take a short break for a medical
13:43 --> 13:45minute learning more about what happens
13:45 --> 13:48after the diagnosis of bladder cancer
13:48 --> 13:50with my guest doctor John Colberg.
13:50 --> 13:53Support for Yale Cancer Answers comes
13:53 --> 13:56from AstraZeneca, providing important
13:56 --> 13:58treatment options for patients
13:58 --> 14:01living with different types of lung,
14:01 --> 14:02bladder, ovarian, breast,
14:02 --> 14:04pancreatic and blood cancers.
14:04 --> 14:08More information at astrazeneca-us.com.
14:08 --> 14:10This is a medical minute
14:10 --> 14:11about smoking cessation.
14:11 --> 14:13There are many obstacles to
14:13 --> 14:15face when quitting smoking,
14:15 --> 14:18as smoking involves the potent drug nicotine.
14:18 --> 14:21But it's a very important lifestyle change,
14:21 --> 14:22especially for patients
14:22 --> 14:23undergoing cancer treatment.
14:23 --> 14:26Quitting smoking has been shown to
14:26 --> 14:28positively impact response to treatments
14:28 --> 14:30decrease the likelihood that patients
14:30 --> 14:32will develop second malignancies
14:32 --> 14:34and increase rates of survival.
14:34 --> 14:36Tobacco treatment programs are
14:36 --> 14:38currently being offered at federally
14:38 --> 14:40designated comprehensive cancer centers.
14:40 --> 14:41And operate on the principles
14:41 --> 14:44of the US Public Health Service
14:44 --> 14:45clinical practice guidelines.
14:46 --> 14:47All treatment components are
14:47 --> 14:49evidence based and therefore all
14:49 --> 14:51patients are treated with FDA
14:51 --> 14:53approved first line medications
14:53 --> 14:56for smoking cessation as well as
14:56 --> 14:57smoking cessation counseling that
14:57 --> 14:59stresses appropriate coping skills.
14:59 --> 15:01More information is available at
15:01 --> 15:03yalecancercenter.org you're listening
15:03 --> 15:04to Connecticut public radio.
15:05 --> 15:07Welcome back to Yale Cancer Answers.
15:07 --> 15:09This is doctor Anees Chagpar
15:09 --> 15:12and I'm joined tonight by
15:12 --> 15:14my guest doctor John Colberg.
15:14 --> 15:16We're talking about the diagnosis
15:16 --> 15:18and treatment of bladder cancer and
15:18 --> 15:20right before the break you
15:20 --> 15:22were telling us about this minimally
15:22 --> 15:24invasive endoscopic biopsy that's
15:24 --> 15:25done to diagnose bladder cancers.
15:25 --> 15:28So I want to pick it up there when
15:28 --> 15:31people have this outpatient procedure
15:31 --> 15:32to diagnose bladder cancers.
15:32 --> 15:34How long does it actually take
15:34 --> 15:36to get that diagnosis back?
15:36 --> 15:39Usually it takes about three to five days.
15:39 --> 15:42It all depends on how complicated or
15:42 --> 15:45if there's some differences in what
15:45 --> 15:47exactly the pathology is or if the pathologist
15:47 --> 15:49may need to do some special stains or
15:50 --> 15:52special studies to really nail down
15:52 --> 15:55exactly what type of tumor it is.
15:55 --> 15:57That brings me to my next question,
15:57 --> 15:59which is, are there different
15:59 --> 16:01types of bladder cancer?
16:01 --> 16:03Or is this a homogeneous disease?
16:03 --> 16:04It sounds like
16:04 --> 16:06there's different types.
16:06 --> 16:08Can you tell us a little
16:08 --> 16:09bit more about that?
16:09 --> 16:11Sure, there's basically three
16:11 --> 16:14different types of bladder cancer.
16:14 --> 16:16There are two very uncommon
16:16 --> 16:18rare types of cancers.
16:18 --> 16:20They're called squamous cell cancers that
16:20 --> 16:23typically occur in men or women
16:23 --> 16:25who have chronic inflammation.
16:25 --> 16:28Infections may be in a tube in the
16:28 --> 16:31bladder for long periods of time.
16:31 --> 16:33The second type is called
16:33 --> 16:35adenocarcinoma.
16:35 --> 16:37Again, very uncommon.
16:37 --> 16:41They usually occur in the top of the bladder.
16:41 --> 16:44A little structure that connects
16:44 --> 16:47the belly button.
16:47 --> 16:49The vast majority of bladder cancers
16:49 --> 16:52are what we call urothelial cancers
16:52 --> 16:55or transitional cell cancers.
16:55 --> 16:56And it's really important that
16:56 --> 16:59the pathologist tells you three things.
16:59 --> 17:01What type of tumor it is, what
17:01 --> 17:03grade the tumor is,
17:03 --> 17:05meaning what it looks like under the
17:05 --> 17:07microscope, is a high grade
17:07 --> 17:08or is it low grade?
17:08 --> 17:11And thirdly he will tell you what
17:11 --> 17:13we call the depth of invasion.
17:13 --> 17:13Meaning,
17:13 --> 17:16how deep does it penetrate the bladder wall?
17:16 --> 17:18or is it superficial, meaning
17:18 --> 17:20just involving the top layer or
17:20 --> 17:22the layer right behind the top
17:22 --> 17:24layer called the lamina propria
17:24 --> 17:27or is it into the muscle?
17:27 --> 17:29Because depending on what the grade is,
17:29 --> 17:30high grade,
17:30 --> 17:32low grade and depending on the
17:32 --> 17:34depth of invasion that will
17:34 --> 17:36dictate or tell us exactly what
17:36 --> 17:38the next steps will be.
17:40 --> 17:42Tell us more about that.
17:44 --> 17:46What does the algorithm look
17:46 --> 17:48like?
17:48 --> 17:50If someone has what we call low grade,
17:50 --> 17:52superficial bladder cancer, and
17:54 --> 17:55it's small,
17:55 --> 17:57meaning less than two or three centimeters,
17:57 --> 17:59most people will just
17:59 --> 18:01follow those patients,
18:01 --> 18:02meaning they will put him
18:02 --> 18:04on a surveillance protocol,
18:04 --> 18:06meaning they'll come back to the
18:06 --> 18:08office every three to six months
18:08 --> 18:09and look into the bladder,
18:09 --> 18:11because what we know about bladder
18:11 --> 18:13cancer is that
18:13 --> 18:15the recurrence rates are quite high,
18:15 --> 18:17so that you want to make sure
18:17 --> 18:19that you follow these men and
18:19 --> 18:22women so you can pick up if it
18:22 --> 18:24does come back at an early stage.
18:24 --> 18:26So it doesn't progress into a
18:26 --> 18:28higher grade tumor or muscle
18:28 --> 18:30invasive tumor, so let
18:30 --> 18:32me just stop you there for one second.
18:32 --> 18:35So if they did a biopsy and they've just
18:35 --> 18:38taken a piece of this cancer before they
18:38 --> 18:41put you on this regimen of surveillance,
18:41 --> 18:43do they actually need to go
18:43 --> 18:45and take out the whole tumor?
18:45 --> 18:48Or is this something that they can just
18:48 --> 18:50watch like a prostate cancer, for example,
18:50 --> 18:52because it tends to be indolent.
18:52 --> 18:55So typically when you go in
18:55 --> 18:57to take the tumor out,
18:59 --> 19:00you actually resect the
19:00 --> 19:02whole tumor if you can.
19:02 --> 19:05So usually for low grade tumors
19:05 --> 19:07you have muscle in the specimen
19:07 --> 19:09and if there's no muscle involved
19:09 --> 19:11then you're basically done.
19:11 --> 19:14You don't have to go back again.
19:14 --> 19:16Now there's some caveats of that.
19:16 --> 19:18If it's a higher grade tumor and
19:18 --> 19:20you don't have muscle involved,
19:20 --> 19:23you will go back and re stage or
19:23 --> 19:25re reset that tumor did to make
19:25 --> 19:28sure that it's not on the muscle.
19:28 --> 19:31So for higher grade tumors
19:31 --> 19:33with no involvement of muscle,
19:33 --> 19:36you may want to consider what we
19:36 --> 19:37call intravesical or treatment
19:37 --> 19:40in the bladder with certain
19:40 --> 19:42different types of medication.
19:42 --> 19:44Usually it's installed over
19:44 --> 19:47once a week for six weeks.
19:47 --> 19:49The medication we typically
19:49 --> 19:50use is something called BCG.
19:50 --> 19:53It's a mycobacterium that
19:53 --> 19:56causes tuberculosis and what it does,
19:56 --> 20:00it sets up an immune response of your own
20:00 --> 20:03to cut down on the
20:03 --> 20:05recurrence of the tumor.
20:05 --> 20:08If it is high grade and muscle invasive
20:08 --> 20:10then that changes the whole scenario
20:10 --> 20:13as far as your treatment algorithm.
20:14 --> 20:16I'm going to get to what
20:16 --> 20:19we do if it's invaded the muscle,
20:19 --> 20:21but the whole concept of installation
20:21 --> 20:24of BCG and the fact that it's a
20:24 --> 20:26mycobacterium kind of like TB,
20:26 --> 20:29brings up a lot of questions that I think our
20:29 --> 20:32listeners might be asking themselves.
20:32 --> 20:34So, for example, if you get this,
20:34 --> 20:37does that put you at risk of actually
20:37 --> 20:39getting tuberculosis number one, and #2
20:40 --> 20:42if you've already had TB in the past,
20:42 --> 20:45does that reduce your risk of
20:45 --> 20:46getting bladder cancer if
20:46 --> 20:48the chemical that we use,
20:48 --> 20:51or the medication that we use
20:51 --> 20:53is actually a mycobacterium.
20:53 --> 20:54You know, people
20:54 --> 20:56looked at that because there's
20:56 --> 20:59several countries outside the US
20:59 --> 21:02that actually vaccinate
21:02 --> 21:05people for TB so it doesn't appear to be
21:05 --> 21:09a prevent you from getting bladder cancer.
21:09 --> 21:12There is a small risk
21:12 --> 21:15that you can get what we call BCGiosis
21:15 --> 21:17or systemic BCG from the treatment.
21:18 --> 21:20It's very, very rare and it's
21:20 --> 21:21usually associated with the
21:21 --> 21:23installation of the medication,
21:23 --> 21:25meaning that when you put the
21:25 --> 21:29medication in you have to put it
21:29 --> 21:32through a catheter
21:35 --> 21:38which is a small tube and most of the cases
21:38 --> 21:42of systemic BCG has been related to
21:42 --> 21:44what we call traumatic catheterization meaning
21:44 --> 21:46that when you put the catheter in an d
21:46 --> 21:48it's been difficult to put in,
21:48 --> 21:49you've gotten blood back from
21:49 --> 21:51the catheter and the
21:51 --> 21:53medication is injected under some force.
21:53 --> 21:56And obviously you don't want to do that.
21:56 --> 21:58So typically in our office if someone
21:58 --> 22:00placed the catheter and they
22:00 --> 22:02get blood during the catheterization,
22:02 --> 22:04they will not give the treatment
22:04 --> 22:05that day.
22:05 --> 22:07John another question
22:07 --> 22:10why is it that we use BCG
22:10 --> 22:12when we think about cancer and
22:12 --> 22:15talk about cancer on the show
22:15 --> 22:17often times when we're thinking
22:17 --> 22:19about medications to treat cancer,
22:19 --> 22:21we're thinking about chemotherapy.
22:21 --> 22:24Rarely do we actually think about
22:24 --> 22:26something like BCG or a mycobacterium.
22:26 --> 22:29Yes, so it starts to set up
22:29 --> 22:32this immune response, which is kind
22:32 --> 22:36of a hot topic with a lot of cancers.
22:36 --> 22:38Now BCG he's been around
22:38 --> 22:40from since the early 1980s,
22:40 --> 22:43and it's been shown to cut down on the
22:43 --> 22:47the incidence of recurrence by about 50%.
22:47 --> 22:50There are other medications used
22:50 --> 22:52intramuscularly, and those tend
22:52 --> 22:54to be chemotherapy agents,
22:54 --> 22:58meaning they kill on contact.
23:03 --> 23:05But their
23:05 --> 23:09response rates are not as good as BCG
23:09 --> 23:11because of this immune
23:11 --> 23:13response that it sets up,
23:13 --> 23:16it sounds like that's really the mechanism
23:16 --> 23:18by which it affects these cancers.
23:18 --> 23:21Which brings me to the question of,
23:21 --> 23:23well, does immunotherapy work
23:23 --> 23:25more in these patients where the
23:25 --> 23:28immune system is kind of revved up?
23:32 --> 23:35That's the hot topic in bladder cancer right now,
23:35 --> 23:38and there's two situations where
23:38 --> 23:41we'd use immunotherapy, one is for
23:41 --> 23:44men or women who have failed BCG
23:44 --> 23:47but still have superficial disease,
23:47 --> 23:50and called CIS or carcinoma insitu
23:50 --> 23:53which is it's
23:53 --> 23:56own sliver of bladder cancer.
23:56 --> 23:59And it's been approved,
23:59 --> 24:01Pembrolizumab has been approved for
24:01 --> 24:04patients in that particular case.
24:04 --> 24:08It's also been approved for people who failed
24:08 --> 24:11or who are ineligible to receive
24:11 --> 24:12chemotherapy for invasive disease.
24:12 --> 24:16So we do start to use it more and
24:16 --> 24:19more in more advanced bladder cancer.
24:21 --> 24:23And so let's let's talk a little bit
24:23 --> 24:25more about the advanced bladder cancer.
24:25 --> 24:27When you say more advanced,
24:27 --> 24:29do you mean invading the muscle?
24:29 --> 24:31Which is where we kind of left
24:31 --> 24:33off in that algorithm, correct?
24:33 --> 24:35So you're talking about what we call T2
24:35 --> 24:37or higher stage bladder cancer
24:37 --> 24:40into the muscle layer of the bladder,
24:40 --> 24:42as seen on the pathology from the
24:42 --> 24:45reception that you did with the telescope.
24:45 --> 24:48And so how are those patients
24:48 --> 24:50treated?
24:50 --> 24:53In the old days we would just take their bladders out,
24:53 --> 24:54or we'd radiate the bladder.
24:54 --> 24:57We found that that the success rate
24:57 --> 24:59of survival was pretty poor,
24:59 --> 25:02less than 50% five year survival.
25:02 --> 25:03So about 15 years ago
25:03 --> 25:06there are a couple of very good
25:06 --> 25:08studies that have looked at using
25:08 --> 25:10chemotherapy both either in the
25:10 --> 25:13adjuvant or neo
25:13 --> 25:16setting meaning before or after surgery.
25:16 --> 25:17This improved the survival
25:17 --> 25:19significantly,
25:19 --> 25:22so that's been kind of the standard
25:22 --> 25:25treatment for most people with
25:25 --> 25:27invasive bladder cancer is to
25:27 --> 25:29receive some form of chemotherapy,
25:29 --> 25:31preferably before surgery,
25:31 --> 25:34before you take the bladder out,
25:34 --> 25:36and typically the regiments
25:36 --> 25:38will include either a two drug
25:38 --> 25:40regiment called Cisplatinum and
25:40 --> 25:43Gemcitabine, or MVAC
25:43 --> 25:46which is short for
25:46 --> 25:48Methotrexate, Vinblastine, Doxorubicin, Cisplatin.
25:49 --> 25:51A lot of patience when you talk to
25:51 --> 25:53them about neoadjuvant chemotherapy or
25:53 --> 25:55getting chemotherapy before surgery
25:55 --> 25:57they say why would I need the surgery then
25:57 --> 26:00if I'm taking the chemotherapy upfront,
26:00 --> 26:02could that kill off all of the
26:02 --> 26:05cancer cells and then maybe I can
26:05 --> 26:06save myself having the surgery,
26:06 --> 26:09especially if that means that you won't
26:09 --> 26:12have to take out my bladder.
26:12 --> 26:14It's a great question and
26:17 --> 26:20there is a response rate of probably 30% more people
26:20 --> 26:22become what we call P0 meaning
26:22 --> 26:25If you do take their bladders out,
26:25 --> 26:28there will be no cancer in the specimen.
26:28 --> 26:31There are two issues, one
26:31 --> 26:33you've got to be very careful
26:33 --> 26:36because it's often times hard to
26:36 --> 26:38determine if they have recurrent
26:38 --> 26:40disease or not in their bladder, and two
26:40 --> 26:43even though you don't take their bladders
26:43 --> 26:45out and the disease may be cured,
26:45 --> 26:47it still can recur.
26:47 --> 26:50So for some patients it's an
26:50 --> 26:52option, but it's not one
26:52 --> 26:53we usually recommend.
26:54 --> 26:57And I guess
26:57 --> 26:59the other thing is that you don't
26:59 --> 27:01really know that every single
27:01 --> 27:03solitary cell of that cancer has
27:03 --> 27:05disappeared after chemotherapy,
27:05 --> 27:08unless you look at every single cell,
27:08 --> 27:10which often means doing more surgery,
27:10 --> 27:12so does the surgery mean
27:12 --> 27:13taking out the whole bladder?
27:13 --> 27:16Is there ever a time when you can
27:16 --> 27:19take out just a part of the bladder
27:19 --> 27:22and put it back together
27:22 --> 27:23again?
27:23 --> 27:25Absolutely there are certain tumors
27:25 --> 27:27and it all depends on the location.
27:27 --> 27:29If it's what we call in
27:29 --> 27:31the dome of the bladder,
27:31 --> 27:33meaning that top part of the bladder
27:33 --> 27:35where you can get good margins,
27:35 --> 27:37you can do a partial cystectomy.
27:37 --> 27:39Unfortunately, that's not where the
27:39 --> 27:41majority of the bladder tumors form,
27:41 --> 27:44so the chance of just doing a partial
27:44 --> 27:46cystectomy is pretty low.
27:46 --> 27:47But in my practice,
27:47 --> 27:50if I see three or four patients a year,
27:50 --> 27:52that's probably a lot that are
27:52 --> 27:54candidates for partial cystectomy.
27:54 --> 27:57So yes, you can do a partial cystectomy
27:57 --> 27:58if it's in the right location
27:58 --> 28:01and so for the rest of the people,
28:01 --> 28:03that means that you're taking
28:03 --> 28:04out their whole bladder.
28:04 --> 28:06And so the question obviously
28:06 --> 28:09becomes what does that mean for
28:09 --> 28:11me in terms of my quality of life?
28:11 --> 28:13I mean, does this mean a stoma?
28:13 --> 28:16How does that work exactly?
28:16 --> 28:18So there are three
28:18 --> 28:20options when you take someone's
28:20 --> 28:22bladder out as far as where
28:22 --> 28:24the urine goes, one is a stoma.
28:24 --> 28:27Or we take a small piece of small
28:27 --> 28:29intestine and we connect the tubes from
28:29 --> 28:33the kidneys and bring it out of the skin
28:33 --> 28:35so it drains into a bag,
28:35 --> 28:3824 hours, seven days a week.
28:38 --> 28:41You can make a continent stoma,
28:41 --> 28:43meaning you take part of the patients
28:43 --> 28:45right colon
28:47 --> 28:49and bring a small piece of intestines up
28:49 --> 28:51and they actually catheterized
28:51 --> 28:54a stoma four to six times a day.
28:54 --> 28:54And thirdly,
28:54 --> 28:56you can actually make a new
28:56 --> 28:58bladder where you take several
28:58 --> 29:00centimeters of small intestine,
29:00 --> 29:02you fashion it into a sphere,
29:06 --> 29:07so everything's on the inside,
29:07 --> 29:09so they urinate normally without
29:09 --> 29:11a bag or without a stoma.
29:12 --> 29:14Doctor John Colberg is a professor
29:14 --> 29:16of urology and director of Urologic
29:16 --> 29:19Oncology at the Yale School of Medicine.
29:19 --> 29:22If you have questions the address is
29:22 --> 29:23canceranswers@yale.edu and past editions
29:23 --> 29:25of the program are available in audio
29:25 --> 29:28and written form at Yalecancercenter.org.
29:28 --> 29:30We hope you'll join us next week to
29:30 --> 29:33learn more about the fight against
29:33 --> 29:36cancer here on Connecticut public radio.

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October 25, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095

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