Guest: Dr. Thomas Keane – Urology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am talking with Dr. Thomas Keane about the treatment of bladder cancer. Dr. Keane once you have diagnosed bladder cancer, how do you treat it?
Dr. Thomas Keane: Again, there is a crucial addition to the diagnosis of bladder cancer and that’s the stage of it. We initially have to make every effort to try and stage the disease. Typically, if we look in at cystoscopy, we will see a tumor, so the next thing is you bring the patient back to the OR, administer a general anesthetic or spinal anesthetic, and then locally resect the tumor from the bladder itself. The best way I can describe that is, if you imagine a balloon, you are scraping the inside of the balloon in order to get this lesion out without bursting the balloon, that’s the trick. Fortunately, it can be well done by many competent urologists, but it is important that we get an adequate sample of the bladder, an adequate sample of the tumor, and that we resect the base of the tumor to see if there is any invasion into the underlying muscle. Bladder cancer can be divided into superficial and invasive bladder cancer. Superficial means that the bladder cancer has not penetrated through the lamina propria, which is a lining on the surface of the bladder; below that lining is the muscle of the bladder and if the tumor penetrates into the muscle of the bladder, then the patient is probably looking at removal of the bladder are certainly a combination of chemotherapy plus radiation to control the growth. Now fortunately, only 15% or so of patients who are diagnosed with bladder cancer start out with muscle invasive bladder cancer. That means that the other 85% have superficial disease, which is good news. So, by superficial disease, that means they can be treated with a local resection using a resectoscope or resection loop passed in through the urethra into the bladder and do not need a major operation. However, once it has been removed, then we must grade the cancer and there are two different systems of grading, but basically it is PUNLMPs are papillary urothelial neoplasm of low malignant potential, that’s the all grade I, grade II is low grade, and grade III is high grade. Then we have to look at the stage of the disease, meaning is it superficial noninvasive such as TA or is it?.
Dr. Linda Austin: so, now it is just in place -- just in that one place?
Dr. Thomas Keane: just in place on the mucosa. Our number two is a T1 lesion, meaning it has gone down into the submucosa.
Dr. Linda Austin: Deeper into the bladder.
Dr. Thomas Keane: Deeper into the bladder. Not into the muscle, but into the lamina propria. There are some centers, which subdivide lamina propria invasion into -- just into the lamina propria into the muscularis mucosa or below the muscularis mucosa. Typically, we have found that to be too pathologist dependent. There is too much variation on reports. So, the highest risk cancer you can have that is superficial would be a high-grade T1 lesion with associated carcinoma in situ. Now carcinoma in situ, it looks like a 02:58 appearance in the bladder itself. It tends to be purely in the mucosa of the bladder, but it can be a very frankly malignant condition. If that is in existence along with the high-grade lesion that is T1, then you would not be wrong to initially discuss taking out the patient’s bladder there and then.
Dr. Linda Austin: So, in other words, just summarize that little piece; it has to do with how cancerous each cell is, what that malignant potential is?
Dr. Thomas Keane: How cancerous each tumor is, not the cells. The cells, if they are high-grade, will look very aggressive and if you associate that with already a superficially-invasive tumor, you know this phenotype or the physical behavior of this tumor is to invade. Now, if you have resected it away, then you will hope that resection plus some treatment into the bladder will be enough to control it and that brings me to the next point as it is not just a surgical removal of the tumor that will suffice because if you just do that with a high-grade tumor, you have an 80% chance that the tumor will regrow and you have a 55% chance that the tumor will progress. By progress, I mean become muscle invasive. So, therefore, we have to come up with some other options. What else can we do? Well, the second thing that we will probably do is six weeks? after the initial resection, we will go back and re-resect that tumor area to make sure that we got all of the tumor out initially and that may sound like what are they doing that again for? Well the fact is there is a feeling that when you disturb these cells and when you have resected these cells, there are now free cells in the urine and you have a lovely fleshy part of the bladder that you have just exposed because you have just cut away the tumor and those cells can implant and then start to grow. So, we come back six weeks later to re-resect that area to make sure there is number one, no remaining cancer, number two, no new cancer, and number three, we may occasionally biopsy other areas that we see to make sure there is no CIS. If that is negative, we will then wait another six weeks and we will offer the patient BCG. We will if the patient had high-risk superficial cancer as I just described. After we?ve gone back the second time, it is my practice to put in mitomycin-C, which is a local chemotherapy administered into the bladder immediately after we have done the second resection in the postoperative recovery area. We give a small dose of that into the bladder, keep it in there for an hour, and then release it. Then we will proceed with, as I mentioned, the BCG.
Dr. Linda Austin: Is that Bacillus Calmette-Gu?rin?
Dr. Thomas E. Keane: Yes. We would proceed with that at six weeks. We do not proceed immediately because unlike mitomycin-C, BCG if it gets into the blood stream, can kill you. It is a TB-type organism, it’s inactivated TB, but it can precipitate exactly the same side effects as TB do and so far as it can set up very severe lung infections, liver infections, and the patient could become very ill and require six months of antituberculous therapy. So, we must wait for six weeks to everything to have healed and then we will offer the patient six cycles, in other words, one cycle per week for six weeks to be administered and then six weeks after that, we will bring the patient back to the operation room and we will re-stage them, we will re-biopsy them, we will re-cystoscope them, and if everything is clear after that, we will then offer the patient cystoscopies on a three-monthly basis for two years and than also at three months, they will get three more cycles of BCG as a maintenance and then six months after that out to two years, they will get three more cycles every six monthly period. So, as you can see, if you do develop bladder cancer, you are going to get to know your urologist extremely well because for the first two years, you will be having at least three-monthly cystoscopies, for two year after that, you will be having six-monthly cystoscopies, and probably for another two years after that, you will be having yearly cystoscopies. So, for the patient who develops high-risk bladder cancer who never recurs, who responds to resection, responds to the re-resection, responds to the mitomycin-C and to the BCG, they are still looking at six years of interaction with the urologist before we will tell them that is likely it isn’t coming back because bladder cancer has a tendency to both recur and to progress and in urologic terms, we don’t mind the recurrences, we can handle them, but we dread the progression because that’s what can kill the patient.
Dr. Linda Austin: It must break your heart when you see bladder cancer caused by smoking or at least associated with smoking, it is so unnecessary.
Dr. Thomas E. Keane: It is disturbing. I think the number of people who smoked throughout the world is phenomenal. I think there are people with it in their history and if you are an ex-smoker, you probably have four times the risk of a person who never smoked of developing bladder cancer. If you are a current smoker, you have nine times the risk of developing bladder cancer and I will say that when I talked to patients who smoke and they have bladder cancer, I find it very disturbing and upsetting that here is somebody who has asked me to try and cure them and the only thing they can do to help themselves is to stop smoking and if they are not prepared to do that, that makes it very difficult for us to turn around and say well okay, we will do our very best to cure you despite the fact that you are doing your very best to nullify that cure because if you continue smoking, bladder cancer is coming back.
Dr. Linda Austin: And then I think it’s may be time to put in a plug that there are some new medications to help people quit smoking to make easier, it is a nasty addiction.
Dr. Thomas E. Keane: Yes and there are some new medications, which are available, there is a number of new products that are on the market, but as I tell all my patients and I often ask them how much more incentive is required other than the fact that you are going to die to get you to stop smoking, I think if they think of it in those terms, they may find it easier to kick their addiction.
Dr. Linda Austin: Those are very thought-provoking words. Thank you Dr. Keane.
Dr. Thomas E. Keane: You are welcome.
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