Guest: Dr. Thomas E. Keane – Urology
Host: Linda Austin, M.D. – Psychiatrist
Dr. Linda Austin: I am Dr. Linda Austin. I am talking today with Dr. Thomas Keane, who is Professor and Chairman of Urology at the Medical University of South Carolina. Dr. Keane, one of your strong areas of interest and contribution has been in the area of bladder cancer, what are some of the first symptoms someone might experience with this illness?
Dr. Thomas E. Keane: Well, bladder cancer is one of the GU malignancies and symptoms typically will tend to be blood in the urine. Now, there are many causes for blood in the urine. It may be detected on the dipstick whereby the patient doesn’t even see the blood or it may be somebody who just pees frank blood. As I said it could be a urinary tract infection, which is responsible for the blood, it could be a stone, it could be an abnormality in the prostate, and it can have many causes. Nonetheless, they should all be investigated and they are to be high-risk and low-risk groups. There are approximately 57,000 new cases diagnosed every year of bladder cancer and there are about 12,000 deaths per year from bladder cancer. As opposed to prostate cancer, if you are diagnosed with bladder cancer that can be very quickly a fatal disease. Patients have a very definite risk of death over a 5-year as opposed to a 20-year period. Among the major causes of bladder cancer is smoking. Not many people realize it, but smoking is a direct contributor and there is a direct link to bladder cancer from nicotine. One of the most upsetting things that I see is the upsurgence in the number of people when they are driving home across the Cooper River Bridge that have their hand out of the window with a cigarette in their hand and the window opens, so it doesn’t smell the car. Most of these tend to be women and I think it is something that is very unfortunate as the men are starting to get the message, but I don’t see the young women getting the same message; may be a useful ad would be a good FISH looking young woman with a urostomy bag attached to her side as being the option if she keeps smoking, that’s what they are facing.
Dr. Linda Austin: So, let’s imagine a patient comes to you with the symptoms or the signs of visible blood in the urine. They are starting to pee red or urine that looks like iced tea, how do you begin to evaluate that patient?
Dr. Thomas E. Keane: First is to conform that it is blood in the urine and that can be done either by looking under a microscope or by using in a dipstick. The second thing then is to reassure them that very frequently it is probably not due to bladder cancer, but more likely a mild urinary tract infection or some other thing. The high-risk groups of the people, who have a history of smoking, people who are over 50 years of age and it tends to be nor men than women who will develop bladder cancer, but either group if they are smokers and they have hematuria, either gross or microscopic, should be considered high risk over 50. If you are in that group, then what is going to happen is you are probably going to have a sample of your urine sent to check it for cytology, which is where the cytologist will look underneath the microscope for abnormal cells consistent with cancer. Second is they will check a fluorescent in-situ hybridization, which we call a FISH test, which looks for the chromatin content and the number of the abnormal chromosomes within the cells themselves and you get the score out of the number of cells checked and then they can come back and say this is more likely to be associated with cancer 03:25. The next thing that will happen will be a CT scan. More typically now it’s a CT of the kidneys and the ureters and the bladder with and without contrast in order to identify any lesion within the kidney or the ureter or the bladder because while bladder cancer is the most common cause of malignant hematuria, you also have a ureter and a kidney up above them, which are lined by the same mucosa that’s lining the bladder. So, you need to make sure that the bleeding isn’t coming from one of those organs rather than the bladder itself. If everything is clear on the bladder are clear on the CT scan, I should say, one can never accept that as evidence that there is not disease within the bladder, you have to look. The reason you have to look is that the contrast of the CT scan may not be accurate enough to show you a small tumor sitting in the bladder, so a cystoscopy is extremely important. With that done, if there is no evidence for anything within the bladder, you don’t see any inflammation, you don’t see any tumor, then you can pretty confidently tell the patient that well, you did have some bleeding, we?ve not found an obvious cause, and that’s a good news because for the time being, we do not think that you have any bladder cancer present, but the evaluation of a patient should take place in that manner whereby the urine cytology is checked, the CT urogram is performed, and the cystoscopy is done. I frequently have patients who will come back and say well my cytology is negative and my CT is negative, do I really need this cystoscopy? My answer to that is absolutely yes.
Dr. Linda Austin: And do some of those patients go on to have unexplained bleeding then for a prolonged period of time or is that unusual?
Dr. Thomas E. Keane: Yes you can certainly -- absolutely, you get a number of patients who will have persistent microscopic hematuria and what we do with those patients is we generally feel that it is something in the kidney itself, which is causing the filtered blood, some of the filtered blood to escape into the ureter and thereby making the test positive. We often have patients who have been evaluated two and three times for microscopic hematuria by different people and nothing ever found, that’s the group of patients who I will tell them that they have asymptomatic or idiopathic microscopic hematuria of no cause that we can find and that they need to know that they will always have some blood in the urine, so not to get to get excited about it unless they find that they actually see blood, which is a totally different situation and makes it even more urgent that the patient to be evaluated.
Dr. Linda Austin: Dr. Keane, thank you very much.
Dr. Thomas E. Keane: You are welcome.
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