Bladder Cancer Awareness

October 26, 2020

Information

October 25, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095

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00:00Support for Yale Cancer Answers comes
00:03from AstraZeneca, focused on exploring
00:05innovative treatment approaches for
00:08people living with bladder cancer.
00:10Learn more at astrazeneca-us.com.
00:14Welcome to Yale Cancer
00:16Answers with your host
00:17Doctor Anees Chagpar.
00:19Yale Cancer Answers features the
00:21latest information on cancer care by
00:23welcoming oncologists and specialists
00:24who are on the forefront of the
00:27battle to fight cancer. This week,
00:28it's a conversation about the diagnosis
00:30and treatment of bladder cancer,
00:32with doctor John Colberg.
00:34Doctor Colberg is a professor of
00:36urology and director of Urologic
00:37Oncology at the Yale School of
00:40Medicine where Doctor Chagpar is
00:41a professor of surgical oncology.
00:45Maybe we can start off by talking
00:47a little bit more about bladder cancer.
00:50It certainly isn't one of the most
00:52common cancers that we think about.
00:55So tell us a little bit more about it.
00:58How common is it? Who gets it, and
01:00how deadly is it?
01:03If you look at non skin cancer cancers,
01:06it's the fifth most common
01:08cancer that we diagnose.
01:10It's the fourth most common in males.
01:14About 80,000 cases are diagnosed a year.
01:17The vast majority are male,
01:20about 62,000 versus 19,000 for women and
01:25the average age of diagnosis is 73.
01:29The chance of a man getting bladder
01:32cancer is about one out of 27 and
01:35for women about one out of 80.
01:40So when you think about it,
01:43being in the top five,
01:45it actually might be more common
01:47than many people realize.
01:49So what are the risk factors?
01:52Are there modifiable things that
01:53people should be thinking about that
01:56may predispose to bladder cancer?
01:57Absolutely, I think the biggest
02:00one is cigarette smoking.
02:02A cigarette smoker has a three times greater
02:06chance of developing bladder cancer.
02:09There's some environmental and
02:11workplace exposures that you
02:13might want to think about which
02:16includes people who
02:19work in textiles,
02:22maybe professions of painters, truck drivers.
02:26And on top of that,
02:28a lot of these people also smoke,
02:31so they have a much higher risk
02:33of developing bladder cancer.
02:35Now there's no predisposing
02:37genetic factors perse.
02:39Most of them are related to being
02:41turned on by cigarette smoking
02:43or environmental exposures.
02:46tI hink with the cigarette smoking
02:47and I'd like to come back to
02:50that in terms of cumulative risk
02:52and whether quitting smoking
02:55actually reduces your risk, but
02:57in terms of workplace exposures,
02:59oftentimes if you're a
03:02painter or a truck driver,
03:04that's your livelihood.
03:06Are there things that people are
03:08doing to reduce some of the exposures
03:11that people get to various chemicals
03:13associated with these occupations?
03:15So, for example,
03:17are there governmental bans
03:19on some of these chemicals that may be
03:23found in paints and dyes and so on?
03:30There's a fairly delayed response to
03:32getting the cancer after this exposure,
03:34so a lot of these men and women we see
03:37have been exposed 20 or 30 years ago or
03:4040 years ago when there weren't a lot
03:44of restrictions and new laws in place
03:46to prevent from limiting their exposure.
03:48But some of them,
03:51truck drivers are exposed to diesel fuel
03:54or people work in the dry cleaning business
03:57are exposed
04:00so I think that we are
04:03more aware of the exposures now and
04:06certainly with cigarette smoking
04:09it's pretty easy to say,
04:11stop smoking.
04:12And sadly though there
04:14really is no legal restrictions on
04:17smoking and so it really is up to
04:19people to take control of their own
04:22health with regards to cigarette
04:23smoking though one of the questions
04:26that often comes up is
04:28people who have engaged in smoking
04:30often find it very difficult
04:32to quit and so they say,
04:36if I've already been smoking
04:38for 10, 15, 20 years,
04:39the damage is already done,
04:42so why bother quitting smoking?
04:44Is the risk of bladder cancer cumulative?
04:47In other words,
04:49you keep adding to that risk
04:52the more you smoke and after a certain point,
04:55if you say quit for five or ten years,
04:59your risk goes back down.
05:01Or is it that
05:03cigarette smoking causes damage
05:05that once it's done is done,
05:07and even if you quit smoking at that point,
05:10you're still at risk of
05:12developing bladder cancer.
05:14I don't think we know
05:16that for certain, but
05:18certainly patients who stop smoking,
05:20I think the recurrence of the
05:22bladder cancer goes down.
05:24So I think that even though it
05:27may not completely absolve them
05:29from getting more bladder cancer,
05:31it certainly will help them.
05:35And so the other thing that's interesting
05:37is that you mentioned that there was this
05:40gender difference in terms
05:42of bladder cancer, with more men
05:45getting bladder cancer than women,
05:46I wonder whether that's related
05:48to differences in smoking.
05:50And now that we are beginning to
05:52see more and more women smoking,
05:55whether they've seen anything
05:56change in terms of the risk of
05:58women developing bladder cancers.
06:01I think that's a reasonable supposition.
06:03We don't see that yet, but I think that
06:06like other types of cancer that may take
06:09several years to kind of catch up.
06:12The other question we've seen in
06:15other cancers is there a synergistic
06:18effect between alcohol and
06:20smoking in terms of cancer risks.
06:24Do we see that in bladder cancer too
06:27or is it really the environmental and
06:31occupational exposures instead of alcohol?
06:35I don't think we've
06:37seen that with alcohol and bladder cancer.
06:44Is the risk higher with people who have an
06:47occupational risk like
06:50being exposed to various chemicals in
06:53the workplace if they are also smokers,
06:56is that just additive,
06:58but a synergistic risk?
07:00Or is it
07:05an additive risk?
07:06I don't think we know for certain,
07:08but I think that anecdotally
07:10it's synergy.
07:11So typically the worst
07:13cancers we see tend to be
07:16in people who have environmental
07:17exposures and they smoke.
07:21And so do we ever see bladder cancer
07:24in people who don't have one of those
07:28two risk factors?
07:31Yes, absolutely.
07:33Are these risk different than others in terms
07:36of how they look biologically?
07:37How they behave, and so on.
07:41I don't think we know that for certain,
07:44but again, not everybody
07:46that smokes gets bladder cancer.
07:49And some people
07:51get bladder cancer, who
07:53don't smoke.
07:54But I guess the definitive message is
07:57if you smoke you are at greater
08:00risk of getting bladder cancer
08:02and so doing what you can to quit
08:05smoking may help you either to
08:07avoid getting bladder cancer to
08:10begin with and reducing your risk
08:12of getting a recurrence.
08:14So let's talk a little bit about bladder
08:18cancer in terms of how it presents.
08:22How do people actually
08:24develop bladder cancer?
08:25What symptoms does that
08:27present with, typically?
08:28Do people with bladder cancer
08:31present with blood in the urine?
08:39Or is it found when he look under
08:41the microscope?
08:47So two questions there.
08:49The first question is,
08:50sometimes when people
08:52find blood in their urine,
08:53they assume that that's something like
08:56a kidney stone or something like that.
08:59How do you differentiate that
09:01from a bladder cancer and how do
09:03you actually find microscopic
09:05material that you can't really see?
09:07Is that something that would then
09:09cause people to present very late?
09:10How is that picked up?
09:13I think that if you have symptoms,
09:19maybe even infection or pain with urination,
09:26pattern changes, some people will
09:28look at your analysis and see if
09:32there's microscopic hematuria
09:33and that's one way that we find a lot of
09:37people just present with blood and
09:41that's how they initially present,
09:43and so in either of those two circumstances,
09:46either you have symptoms of an infection
09:49or pain, or frequency of going,
09:53or you actually see blood in your urine, you
09:56go to your family doctor and they do a
10:00test and they find blood in your urine.
10:02What's the next step?
10:04The first thing you want
10:05to look at is
10:07do they have symptoms of an infection?
10:10So if they have symptoms of infection,
10:12they need to treat the infection and the blood
10:15should go away, if it doesn't go
10:17away or the symptoms don't
10:20get better after treating infection
10:22then you need what we call the
10:25work up of the blood in the urine
10:27and that work up usually entails
10:30some type of an X Ray study like a CT
10:33scan or an MRI because you can bleed
10:36from any part of the urinary tract,
10:38the lining of the kidneys, the kidney itself,
10:44the bladder itself,
10:45so you want to image or
10:47look at the kidneys
10:50with the CT scan
10:52and then
10:55you also want to look into the bladder,
10:58and that's usually an office procedure
11:00where you take a small telescope
11:02with the light at the end of it and
11:05actually look into the bladder and can
11:07visualize the lining of the bladder.
11:10And so if you do that,
11:14people often ask what does
11:17cancer look like? Will you see
11:20in the bladder the tumor growth?
11:25You'll actually see it emanating
11:26from the bladder wall.
11:28It may look a little like cauliflower
11:31or papillary
11:33growth in the bladder,
11:35or it could be something as subtle
11:37as a redness in the bladder,
11:39or could be a solid mass in the bladder.
11:43So all those are related to
11:47what that looks like under the
11:50microscope once you take that out,
11:53because lower grade tumors
11:54tend to be more papillary,
11:56meaning they're not as aggressive in
11:58higher grade tumors tend to be more solid.
12:02So how do
12:03you exactly take out this cancer
12:05in order to find out under the
12:08microscope what it looks like?
12:10That sounds like a biopsy to me.
12:13So how exactly is that done?
12:16We usually schedule the person
12:20in the operating room
12:23with the anesthesia so that you
12:29go in with a telescope, a little
12:31bigger telescope and
12:33through that telescope we're able
12:35to trim or cut the tissue out.
12:38Usually we could remove
12:40all the tumor itself,
12:43and then we take that tissue
12:45to pathology so they
12:47can analyze it.
12:49It sounds like that's a little operation,
12:51not a big operation because
12:53you're still using a telescope.
12:55It doesn't sound like this is
12:56a big cut in the abdomen and
12:59you're removing the bladder.
13:01It sounds minimally
13:03invasive. Is that right?
13:07Yes, oftentimes it's done as an outpatient.
13:09Occasionally the patient will require
13:11a tube in the bladder overnight,
13:13or for a couple days, depending on how
13:16much you have to do, but the real
13:20risks of the procedure is bleeding,
13:23because obviously you're cutting tissue,
13:25but you're able to also
13:28cauterize the area. Rarely
13:31opening the bladder can
13:33perforate the bladder,
13:36but those are very uncommon.
13:39Well, we're going to pick up right after
13:41we take a short break for a medical
13:44minute learning more about what happens
13:46after the diagnosis of bladder cancer
13:48with my guest doctor John Colberg.
13:51Support for Yale Cancer Answers comes
13:54from AstraZeneca, providing important
13:56treatment options for patients
13:58living with different types of lung,
14:01bladder, ovarian, breast,
14:03pancreatic and blood cancers.
14:05More information at astrazeneca-us.com.
14:08This is a medical minute
14:11about smoking cessation.
14:12There are many obstacles to
14:14face when quitting smoking,
14:16as smoking involves the potent drug nicotine.
14:18But it's a very important lifestyle change,
14:21especially for patients
14:23undergoing cancer treatment.
14:24Quitting smoking has been shown to
14:26positively impact response to treatments
14:28decrease the likelihood that patients
14:31will develop second malignancies
14:33and increase rates of survival.
14:34Tobacco treatment programs are
14:36currently being offered at federally
14:38designated comprehensive cancer centers.
14:40And operate on the principles
14:42of the US Public Health Service
14:44clinical practice guidelines.
14:46All treatment components are
14:48evidence based and therefore all
14:50patients are treated with FDA
14:52approved first line medications
14:53for smoking cessation as well as
14:56smoking cessation counseling that
14:58stresses appropriate coping skills.
15:00More information is available at
15:02yalecancercenter.org you're listening
15:03to Connecticut public radio.
15:06Welcome back to Yale Cancer Answers.
15:08This is doctor Anees Chagpar
15:10and I'm joined tonight by
15:12my guest doctor John Colberg.
15:14We're talking about the diagnosis
15:16and treatment of bladder cancer and
15:18right before the break you
15:21were telling us about this minimally
15:23invasive endoscopic biopsy that's
15:24done to diagnose bladder cancers.
15:26So I want to pick it up there when
15:29people have this outpatient procedure
15:31to diagnose bladder cancers.
15:33How long does it actually take
15:35to get that diagnosis back?
15:36Usually it takes about three to five days.
15:40It all depends on how complicated or
15:43if there's some differences in what
15:45exactly the pathology is or if the pathologist
15:47may need to do some special stains or
15:50special studies to really nail down
15:52exactly what type of tumor it is.
15:55That brings me to my next question,
15:58which is, are there different
16:00types of bladder cancer?
16:01Or is this a homogeneous disease?
16:03It sounds like
16:05there's different types.
16:06Can you tell us a little
16:08bit more about that?
16:10Sure, there's basically three
16:12different types of bladder cancer.
16:14There are two very uncommon
16:16rare types of cancers.
16:18They're called squamous cell cancers that
16:20typically occur in men or women
16:23who have chronic inflammation.
16:25Infections may be in a tube in the
16:28bladder for long periods of time.
16:31The second type is called
16:34adenocarcinoma.
16:36Again, very uncommon.
16:38They usually occur in the top of the bladder.
16:42A little structure that connects
16:44the belly button.
16:47The vast majority of bladder cancers
16:50are what we call urothelial cancers
16:53or transitional cell cancers.
16:55And it's really important that
16:57the pathologist tells you three things.
16:59What type of tumor it is, what
17:01grade the tumor is,
17:03meaning what it looks like under the
17:05microscope, is a high grade
17:07or is it low grade?
17:09And thirdly he will tell you what
17:11we call the depth of invasion.
17:14Meaning,
17:14how deep does it penetrate the bladder wall?
17:17or is it superficial, meaning
17:19just involving the top layer or
17:21the layer right behind the top
17:23layer called the lamina propria
17:25or is it into the muscle?
17:27Because depending on what the grade is,
17:30high grade,
17:30low grade and depending on the
17:32depth of invasion that will
17:34dictate or tell us exactly what
17:36the next steps will be.
17:40Tell us more about that.
17:44What does the algorithm look
17:46like?
17:48If someone has what we call low grade,
17:51superficial bladder cancer, and
17:54it's small,
17:55meaning less than two or three centimeters,
17:58most people will just
18:00follow those patients,
18:01meaning they will put him
18:03on a surveillance protocol,
18:04meaning they'll come back to the
18:06office every three to six months
18:08and look into the bladder,
18:10because what we know about bladder
18:12cancer is that
18:14the recurrence rates are quite high,
18:16so that you want to make sure
18:18that you follow these men and
18:20women so you can pick up if it
18:23does come back at an early stage.
18:25So it doesn't progress into a
18:27higher grade tumor or muscle
18:29invasive tumor, so let
18:30me just stop you there for one second.
18:33So if they did a biopsy and they've just
18:36taken a piece of this cancer before they
18:38put you on this regimen of surveillance,
18:41do they actually need to go
18:43and take out the whole tumor?
18:46Or is this something that they can just
18:48watch like a prostate cancer, for example,
18:51because it tends to be indolent.
18:53So typically when you go in
18:55to take the tumor out,
18:59you actually resect the
19:01whole tumor if you can.
19:02So usually for low grade tumors
19:05you have muscle in the specimen
19:07and if there's no muscle involved
19:10then you're basically done.
19:12You don't have to go back again.
19:14Now there's some caveats of that.
19:16If it's a higher grade tumor and
19:18you don't have muscle involved,
19:21you will go back and re stage or
19:23re reset that tumor did to make
19:26sure that it's not on the muscle.
19:29So for higher grade tumors
19:31with no involvement of muscle,
19:34you may want to consider what we
19:36call intravesical or treatment
19:38in the bladder with certain
19:41different types of medication.
19:43Usually it's installed over
19:45once a week for six weeks.
19:47The medication we typically
19:49use is something called BCG.
19:51It's a mycobacterium that
19:54causes tuberculosis and what it does,
19:56it sets up an immune response of your own
20:00to cut down on the
20:03recurrence of the tumor.
20:05If it is high grade and muscle invasive
20:08then that changes the whole scenario
20:11as far as your treatment algorithm.
20:14I'm going to get to what
20:17we do if it's invaded the muscle,
20:20but the whole concept of installation
20:22of BCG and the fact that it's a
20:25mycobacterium kind of like TB,
20:27brings up a lot of questions that I think our
20:30listeners might be asking themselves.
20:32So, for example, if you get this,
20:35does that put you at risk of actually
20:38getting tuberculosis number one, and #2
20:40if you've already had TB in the past,
20:43does that reduce your risk of
20:45getting bladder cancer if
20:47the chemical that we use,
20:49or the medication that we use
20:52is actually a mycobacterium.
20:53You know, people
20:55looked at that because there's
20:57several countries outside the US
21:00that actually vaccinate
21:02people for TB so it doesn't appear to be
21:06a prevent you from getting bladder cancer.
21:09There is a small risk
21:12that you can get what we call BCGiosis
21:15or systemic BCG from the treatment.
21:18It's very, very rare and it's
21:20usually associated with the
21:22installation of the medication,
21:23meaning that when you put the
21:26medication in you have to put it
21:29through a catheter
21:36which is a small tube and most of the cases
21:38of systemic BCG has been related to
21:42what we call traumatic catheterization meaning
21:44that when you put the catheter in an d
21:47it's been difficult to put in,
21:48you've gotten blood back from
21:50the catheter and the
21:52medication is injected under some force.
21:53And obviously you don't want to do that.
21:56So typically in our office if someone
21:58placed the catheter and they
22:00get blood during the catheterization,
22:02they will not give the treatment
22:05that day.
22:06John another question
22:07why is it that we use BCG
22:10when we think about cancer and
22:13talk about cancer on the show
22:16often times when we're thinking
22:18about medications to treat cancer,
22:20we're thinking about chemotherapy.
22:22Rarely do we actually think about
22:24something like BCG or a mycobacterium.
22:27Yes, so it starts to set up
22:30this immune response, which is kind
22:32of a hot topic with a lot of cancers.
22:36Now BCG he's been around
22:38from since the early 1980s,
22:40and it's been shown to cut down on the
22:44the incidence of recurrence by about 50%.
22:48There are other medications used
22:50intramuscularly, and those tend
22:52to be chemotherapy agents,
22:55meaning they kill on contact.
23:04But their
23:06response rates are not as good as BCG
23:09because of this immune
23:12response that it sets up,
23:14it sounds like that's really the mechanism
23:16by which it affects these cancers.
23:19Which brings me to the question of,
23:22well, does immunotherapy work
23:23more in these patients where the
23:26immune system is kind of revved up?
23:32That's the hot topic in bladder cancer right now,
23:35and there's two situations where
23:39we'd use immunotherapy, one is for
23:42men or women who have failed BCG
23:44but still have superficial disease,
23:47and called CIS or carcinoma insitu
23:50which is it's
23:54own sliver of bladder cancer.
23:56And it's been approved,
23:59Pembrolizumab has been approved for
24:02patients in that particular case.
24:04It's also been approved for people who failed
24:09or who are ineligible to receive
24:11chemotherapy for invasive disease.
24:13So we do start to use it more and
24:16more in more advanced bladder cancer.
24:21And so let's let's talk a little bit
24:23more about the advanced bladder cancer.
24:26When you say more advanced,
24:27do you mean invading the muscle?
24:29Which is where we kind of left
24:32off in that algorithm, correct?
24:33So you're talking about what we call T2
24:36or higher stage bladder cancer
24:38into the muscle layer of the bladder,
24:40as seen on the pathology from the
24:43reception that you did with the telescope.
24:46And so how are those patients
24:48treated?
24:51In the old days we would just take their bladders out,
24:53or we'd radiate the bladder.
24:55We found that that the success rate
24:57of survival was pretty poor,
25:00less than 50% five year survival.
25:02So about 15 years ago
25:04there are a couple of very good
25:06studies that have looked at using
25:09chemotherapy both either in the
25:11adjuvant or neo
25:13setting meaning before or after surgery.
25:16This improved the survival
25:18significantly,
25:19so that's been kind of the standard
25:22treatment for most people with
25:25invasive bladder cancer is to
25:27receive some form of chemotherapy,
25:30preferably before surgery,
25:31before you take the bladder out,
25:34and typically the regiments
25:36will include either a two drug
25:39regiment called Cisplatinum and
25:41Gemcitabine, or MVAC
25:43which is short for
25:46Methotrexate, Vinblastine, Doxorubicin, Cisplatin.
25:50A lot of patience when you talk to
25:51them about neoadjuvant chemotherapy or
25:53getting chemotherapy before surgery
25:55they say why would I need the surgery then
25:58if I'm taking the chemotherapy upfront,
26:00could that kill off all of the
26:03cancer cells and then maybe I can
26:05save myself having the surgery,
26:07especially if that means that you won't
26:10have to take out my bladder.
26:13It's a great question and
26:18there is a response rate of probably 30% more people
26:20become what we call P0 meaning
26:23If you do take their bladders out,
26:26there will be no cancer in the specimen.
26:29There are two issues, one
26:32you've got to be very careful
26:34because it's often times hard to
26:36determine if they have recurrent
26:38disease or not in their bladder, and two
26:41even though you don't take their bladders
26:43out and the disease may be cured,
26:46it still can recur.
26:47So for some patients it's an
26:50option, but it's not one
26:52we usually recommend.
26:55And I guess
26:58the other thing is that you don't
27:00really know that every single
27:01solitary cell of that cancer has
27:04disappeared after chemotherapy,
27:05unless you look at every single cell,
27:08which often means doing more surgery,
27:10so does the surgery mean
27:12taking out the whole bladder?
27:14Is there ever a time when you can
27:17take out just a part of the bladder
27:19and put it back together
27:22again?
27:24Absolutely there are certain tumors
27:25and it all depends on the location.
27:28If it's what we call in
27:30the dome of the bladder,
27:31meaning that top part of the bladder
27:34where you can get good margins,
27:36you can do a partial cystectomy.
27:38Unfortunately, that's not where the
27:40majority of the bladder tumors form,
27:42so the chance of just doing a partial
27:45cystectomy is pretty low.
27:46But in my practice,
27:48if I see three or four patients a year,
27:51that's probably a lot that are
27:53candidates for partial cystectomy.
27:54So yes, you can do a partial cystectomy
27:57if it's in the right location
27:59and so for the rest of the people,
28:01that means that you're taking
28:03out their whole bladder.
28:05And so the question obviously
28:07becomes what does that mean for
28:09me in terms of my quality of life?
28:11I mean, does this mean a stoma?
28:14How does that work exactly?
28:16So there are three
28:19options when you take someone's
28:20bladder out as far as where
28:22the urine goes, one is a stoma.
28:25Or we take a small piece of small
28:27intestine and we connect the tubes from
28:30the kidneys and bring it out of the skin
28:33so it drains into a bag,
28:3624 hours, seven days a week.
28:39You can make a continent stoma,
28:41meaning you take part of the patients
28:44right colon
28:47and bring a small piece of intestines up
28:49and they actually catheterized
28:51a stoma four to six times a day.
28:54And thirdly,
28:55you can actually make a new
28:57bladder where you take several
28:59centimeters of small intestine,
29:01you fashion it into a sphere,
29:06so everything's on the inside,
29:08so they urinate normally without
29:10a bag or without a stoma.
29:13Doctor John Colberg is a professor
29:15of urology and director of Urologic
29:17Oncology at the Yale School of Medicine.
29:20If you have questions the address is
29:22canceranswers@yale.edu and past editions
29:24of the program are available in audio
29:26and written form at Yalecancercenter.org.
29:28We hope you'll join us next week to
29:31learn more about the fight against
29:33cancer here on Connecticut public radio.