MD Anderson Cancer Center
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>> Welcome to Cancer Newsline, a weekly podcast series from The University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Today, our guest is Colin Dinney, he is the Professor and Chairman of the Urology Department here at MD Anderson and we're going to be talking about bladder cancer today. Welcome, Dr. Dinney.
>> Thank you and good morning!
>> Let's talk about the incidence of bladder cancer. I had no idea it was as common as it was. What are the facts and figures?
>> Well, bladder cancer is actually a fairly common disease and most people aren't aware of that. It's the fourth most commonly diagnosed cancer in men and the eighth most commonly diagnosed cancer in women. But really the incidence of the disease doesn't--doesn't really register the full impact of the disease because more individuals are diagnosed with it, with bladder cancer, than die of bladder cancer so the prevalence is actually very high.
>> What are the risk factors for bladder cancer? I think smoking is one because the chemicals in the cigarettes often tend to sit in the lining of the bladder but what are the risk factors?
>> And that's a very good question and in fact it's only recently are people beginning to realize that cigarettes smoking is the most commonly--common cause of bladder cancer. Probably close to 50 percent of the cancers that we see today are secondary to bladder cancer--are secondary to cigarette smoking. Other risk factors would include environmental exposures, exposures that can be seen in the petrochemical industries, other industries dyes, other chemical plants, rubber--rubber et cetera these are all, you know, high risk occupations for bladder cancer. Thankfully, most of the known toxins that cause bladder cancer have been taken off the shelf and out of contact from individuals in those fields.
>> So I guess that might in part explain why men are more likely to get it then--'cause they might be in these industries and exposed to these compounds?
>> Yeah, that--that's true. I think the male to female incidence is about three to one. So three times as many men are diagnosed with this cancer and it's thought that it's likely due to the, you know, perhaps in the past a higher incidence of smoking in men and also the environmental exposures. And that may take time. That may change over time. But you have to keep in mind that the latency period, the time from the actual exposure to the time you develop cancer can be anywhere from 15 to 40 years. So it may take a long time for us to see any changes in the--in the incidence of disease according to gender.
>> As far as symptoms, I believe that blood in the urine is probably the most common. But what are other symptoms that people may recognize?
>> Well, actually painless hematuria or blood in the urine is the most common symptom that leads to the diagnosis. Some of these cancers are picked up actually accidentally and people go in with--to the doctors or checkups and have a urinalysis done. And the urinalysis might show microscopic hematuria. Now other--other symptoms that you might associate with bladder cancers such as frequency of urination or painful urination, those things are may occur in cancer but are most likely associated with a benign urological conditions such as an infection or stone disease or things like that, not necessarily with bladder cancer.
>> What does blood in the urine look like? I mean, I think people have this vision that your urine is bright red but that's really not true.
>> I mean it can be--it can be bright red, you may see clots in the urine, you may see sort of a brownish tinged urine and it comes and goes. So you may have blood in the urine once then you may not see it again for two or three months. But seeing it once is important. And that's the issue, it comes and goes.
>> And I guess all tumors occur in the lining of the bladder?
>> The most common cancers do occur on the lining of the bladder and thankfully most of the tumors are actually confined to the very outermost portion of the lining and don't invade deep into the bladder.
>> But aren't there cancers that happen in the ureters, the tubes that go from the kidneys to the bladder?
>> Yeah, I mean again the ureters and the inside of the kidney are lined by the same types of cells that line the bladder. And so those--they are also subject to developing cancer in, you know, I guess because of their exposure to the same carcinogens that cause the bladder cancer. Now the frequency of cancer in the bladder is much more common because the bladder is a reservoir, the urine sits in contact with the lining longer and really the ureters and the kidney they're really being exposed to carcinogens that are in transit so the contact time isn't as--isn't as great.
>> Let's talk about treatment. I'm assuming that surgery may be the frontline treatment?
>> Sure again it's important when your talking about treatment to speak in context of the tumor and most of these tumors are what we call non-muscle invasive or superficial. They don't invade beneath the lining of the bladder. And so those tumors can be treated by what's called a transurethral section where you'll actually go in with an endoscope which is like a telescope with a light, view the tumor and then using a cautery cut the tumor and surrounding tissue away. That tissue is then examined by the pathologist who tells you whether it tells you it's a high risk tumor or low risk tumors. And oftentimes you can tell by the appearance of low risk versus high risk tumors. Low risk tumors tend to look like mulberry or a cauliflower or seaweed growing on the ocean floor. And they have a very distinct appearance and when you see that you can be fairly certain it is a low grade tumor a low risk tumor. Often we give a single dose of chemotherapy after the reception to prevent a recurrent.
>> Are you doing minimally invasive surgery such as robotics or laparoscopy?
>> Well I think robotic surgery--we are doing some robotic surgery in bladder cancer. I think that it's a very--it's a very challenging operation to do it robotically because of the time--the time that it takes and the various steps involved. I don't think that robotic surgery has become a common place in treating bladder cancer the same is it has in say prostate cancer or laparoscopic surgery as in renal cancer. But certainly it can be done. And in expert hands, it's probably done well. But the fact is because most--and people don't have this--a lot of exposure to this disease and do a lot of these operations then the number of individuals who are trained to do it robotically are quite small. And for this cancer especially in this surgical procedure, outcomes are certainly related to the experience of the surgeon.
>> Lets talk about BCG.
>> Is that still a treatment? First of all I don't remember what BCG stands for.
>> Yeah, BCG is Bacillus Calmette-Guerin which is actually a form of the tuberculosis vaccine. And it's an immunotherapy. It's given as a topical therapy, placed into the bladder via a catheter where it gains exposure to the bladder and what it does is it mounts an immune response to prevent the recurrence of bladder cancer. Now BCG as I said earlier, the majority of cancers that are diagnosed are non-muscle invasive, there are a subset of those tumors which have more adverse features microscopically they are picked up by the pathologist and those tumors have a higher risk of recurring and also have a real risk of progressing to muscle invasive disease and beyond where again, the outcome becomes worse and the treatment becomes more extensive. So BCG is used for individuals who have higher risk non-muscle invasive disease so the cells look angry to the pathologist under a microscope. They're starting to invade minimally into the wall of the bladder or there's a condition called carcinoma in situ which is again a form of high grade cancer confined to the lining. If the pathologist reports any of these features then BCG would be considered. And it does reduce the rate of occurrence and does reduce the rate of progression or at least delays progression.
>> How many bladder cancer patients get to keep their bladder and their urinary function?
>> The majority of patients with bladder cancer will keep their bladder. I think that if you look at the statistics probably about 60 percent who will present with low risk disease and maybe only 5 or 6 percent of those will progress, you'll have maybe a 10 to 15 percent with the higher risk disease of non-muscle invasive disease who half of those will lose their bladder. And then if the patients who have--who present with more advanced disease, many of those patients will lose their bladder because the removal of the bladder is the best local treatment for more advanced disease.
>> But from what I understand the urostomy bag is--I mean there are thing like the Studer pouch I mean there are reconstructive surgeries that allow them to have a bladder inside their body as opposed to a urostomy.
>> That's correct. So there are lot of options for diversions. As I said, there are ostomy bags for what's called ileal conduits and then you can build a new bladder called neobladders or new bladders out of intestines. And hook it up to the urethra to allow you know as near a normal urinary function as possible.
>> Let's talk about research. You say there are some clinical trials, nothing ready for primetime yet but what sort of direction are you moving? Is it new surgical techniques? Is it targeted therapies or?
>> That's a very good question. There're a lot of different avenues that are being explored in bladder cancer. I think that one of the most in--one of the things to keep in mind is bladder cancer is a very, very expensive disease to treat because of the nature of our practice. The majority of individuals have low risk disease. But we still don't know which of those people are going to recur, which are gonna progress. And so we sort of treat it by the same. They come in for cystostomies every 3 months, they have urine test in every 3 months and so we need to find better ways using tools that are available to us to identify individuals who at a higher risk and having recurrence so we can survey them more frequently and then cut back on the surveillance of individuals who are less likely to recur. We also need to develop better urinary markers for identifying low risk disease because the markers that we use in our practice today are very effective for identifying high grade disease but not for identifying majority of the low risk tumors. So if we're going to find ways to replace cystoscopy with a marker we have to have a marker that is more reliable at picking up cancer. And that's work that is being done in many places across the country including our own. With respect to targeted therapy again, there's a lot of interest in pursuing targeted therapy. And that means trying to personalize cancer therapy based upon the properties of one's own tumor. And again I think that there are--small steps are being made along that path. And without being too technical, bladder cancers actually are very ideal organ site for doing that. Because in individuals, because we tend to-- in individuals who are undergoing radical cystectomy, that's removal of the bladder, we tend to do a biopsy before and then we tend to take out the bladder afterwards. And we have tissue available that can help direct us towards characterizing that tumor and perhaps even use that information if someone got a treatment between to identifying individuals based upon the tumor characteristics as to pick up and identify who might respond to a specific treatment. And in fact we have several trials ongoing here at MD Anderson to do just that.
>> In closing, is there any message you'd like to say to the audience about bladder cancer?
>> Well I think the biggest I think that as we move on I think that chemo prevention is the most important approach one should take in and bladder cancer, chemo prevention tends to be behavioral. So I think that what you should do is listen to your mother and eat your vegetables, eat your broccoli and your cruciferous vegetables, drink plenty of fluids and don't smoke. I think if we can get the message across that cigarette smoking is the most common cause of bladder cancer that I think we can make real progress in minimizing the misery associated with this disease.
>> Great, thank you Dr. Danny.
>> Thank you.
>> If you have questions about anything you've heard today on Cancer Newsline, contact ask MD Anderson at 1877-MDA-6789 or online at www.mdanderson.org/ask. [Background Music] Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.
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