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INFORMATION FOR

Bladder Cancer Awareness

October 26, 2020
  • 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.