Bladder Cancer: Beyond the Statistics

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:14latest information on cancer care
00:14 --> 00:15by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:19of the battle to fight cancer.
00:19 --> 00:21This week it's a conversation about
00:21 --> 00:23caring for patients with bladder
00:23 --> 00:25cancer with doctor Fed Ghali. Dr.
00:25 --> 00:27Ghali is an assistant professor of
00:27 --> 00:29urology at the Yale School of Medicine,
00:29 --> 00:32where Doctor Chagpar is a professor
00:32 --> 00:34of surgical oncology.
00:34 --> 00:35Fed, maybe you can start off by telling
00:35 --> 00:37us a little bit more about
00:37 --> 00:39yourself and what it is you do.
00:39 --> 00:41I'm in the Department of Urology
00:41 --> 00:44and my focus is urologic cancers.
00:44 --> 00:47So that includes cancers of the prostate
00:47 --> 00:50and kidney and bladder as well as the
00:50 --> 00:52ureter and some other malignancies.
00:52 --> 00:54And my focus even within
00:54 --> 00:55that is urothelial cancers,
00:55 --> 00:58which would be bladder cancer
00:58 --> 01:00and cancers of the ureter.
01:00 --> 01:03So that's my main clinical focus.
01:03 --> 01:05And I also have some research interests
01:05 --> 01:08at the School of Medicine which also
01:08 --> 01:10involve bladder cancer primarily.
01:11 --> 01:13So let's talk a little bit
01:13 --> 01:14more about bladder cancer.
01:14 --> 01:17Can you give us a landscape of
01:17 --> 01:19how common it is, who gets it?
01:19 --> 01:21What are the risk factors?
01:21 --> 01:24Of course, bladder cancer is
01:24 --> 01:26unfortunately quite common.
01:26 --> 01:27Depending on the breakdown,
01:27 --> 01:31it's either the 5th or the 6th most
01:31 --> 01:34common cancer affecting Americans.
01:34 --> 01:36Approximately 80 to a little over
01:36 --> 01:3982,000 Americans will be diagnosed
01:39 --> 01:41with bladder cancer every year.
01:41 --> 01:44So unfortunately it affects a
01:44 --> 01:46lot of patients and of those
01:46 --> 01:48patients the mortality is higher
01:48 --> 01:50than we would like to see.
01:50 --> 01:51You know, approximately over
01:51 --> 01:5316,000 Americans succumb to
01:53 --> 01:55bladder cancer every year.
01:55 --> 01:57So it's a real medical
01:57 --> 01:59problem that we see.
02:01 --> 02:03Bladder cancer primarily
02:03 --> 02:06affects both men and women of course,
02:06 --> 02:08but it affects men more commonly than women,
02:08 --> 02:10actually about three times more
02:10 --> 02:13commonly than women and
02:13 --> 02:15that's what we see in practice as well.
02:15 --> 02:17We definitely see it affecting
02:17 --> 02:19male patients more frequently,
02:19 --> 02:21not that female patients don't get it,
02:21 --> 02:25but just less commonly.
02:25 --> 02:28So that's sort of a basic landscape
02:28 --> 02:31and there are some risk factors
02:31 --> 02:33like you say for bladder cancer.
02:33 --> 02:38By far the most common risk factor we
02:38 --> 02:41see here in the United States is smoking.
02:41 --> 02:45Smoking increases patients risks for
02:45 --> 02:48developing bladder cancer three to four
02:48 --> 02:50times higher than the general population.
02:50 --> 02:53It's a really important
02:53 --> 02:54one because it's so modifiable.
02:56 --> 02:58That's something we have a
02:58 --> 03:02clear impact on in terms of our health.
03:02 --> 03:03There are other risk factors.
03:03 --> 03:05There are certain chemical
03:05 --> 03:07dyes and certain exposures,
03:07 --> 03:08workplace exposures,
03:08 --> 03:10specifically certain types of chemicals
03:10 --> 03:12that are associated with bladder cancer.
03:12 --> 03:15Those are less commonly seen here in
03:15 --> 03:17the United States but can be seen
03:17 --> 03:19and there are certain infections and
03:19 --> 03:21other medical exposures that are less
03:21 --> 03:23common here in the United States but are
03:23 --> 03:25seen more in other parts of the world
03:25 --> 03:27that can be related to bladder cancer.
03:27 --> 03:29Certain parasite infections of the
03:29 --> 03:32bladder which are seen more in the
03:32 --> 03:34Mediterranean and in North Africa
03:34 --> 03:36specifically a parasite called
03:36 --> 03:38schistosomiasis can be related to the
03:38 --> 03:41development of a type of bladder cancer.
03:42 --> 03:44So definitely multiple risk factors,
03:44 --> 03:45but I would say smoking is
03:45 --> 03:47the main one that
03:47 --> 03:49we see here in the in the United
03:49 --> 03:51States and the main one that I
03:51 --> 03:53like to focus on with my patients
03:53 --> 03:55because we have such a clear impact on that.
03:57 --> 03:59And one of the
03:59 --> 04:01things with smoking of course is
04:01 --> 04:03that it's really hard to quit.
04:05 --> 04:07So a couple of questions
04:07 --> 04:08with regards to that.
04:08 --> 04:11First, let's suppose you are a smoker
04:11 --> 04:14and you did develop bladder cancer.
04:14 --> 04:17If you quit,
04:17 --> 04:20does that reduce your risk of recurrence?
04:20 --> 04:24Second, if you're a smoker and you
04:24 --> 04:26haven't developed bladder cancer,
04:26 --> 04:27is it too late?
04:27 --> 04:30In other words, if you quit now,
04:30 --> 04:32do you reduce or potentially
04:32 --> 04:34even eliminate your risk for
04:34 --> 04:36developing bladder cancer?
04:37 --> 04:39Those are both excellent questions.
04:39 --> 04:41I'm glad that you brought those
04:41 --> 04:43points up. To your first question,
04:43 --> 04:46if you have bladder cancer and are a smoker,
04:46 --> 04:48does squitting smoking improve your
04:48 --> 04:50outcomes in any meaningful way?
04:50 --> 04:52And the answer to that is
04:52 --> 04:53almost certainly yes, it does.
04:53 --> 04:56We know that quitting smoking
04:56 --> 04:58even after diagnosis decreases some but not all.
04:59 --> 05:00It's not a huge, huge margin.
05:00 --> 05:02It's not the same as some
05:02 --> 05:03of the other treatments,
05:03 --> 05:05but it's definitely detectable that
05:05 --> 05:08it decreases the risk of bladder
05:08 --> 05:11cancer recurring again in the future.
05:11 --> 05:13So it's something that I encourage
05:13 --> 05:15all my patients
05:15 --> 05:17to really think about and
05:17 --> 05:18consider because sometimes,
05:18 --> 05:19like you say,
05:19 --> 05:21quitting smoking is a very big
05:21 --> 05:23challenge and sometimes the diagnosis
05:23 --> 05:25like this is just the impetus
05:25 --> 05:27and just the motivation one needs
05:27 --> 05:30to take that leap.
05:33 --> 05:36Your second question is if you quit
05:36 --> 05:39smoking before a diagnosis of bladder cancer,
05:39 --> 05:41does it decrease your risk of
05:41 --> 05:42developing it or once you're a smoker,
05:42 --> 05:44sort of always a smoker,
05:44 --> 05:46you've incurred that risk.
05:46 --> 05:48And again,
05:48 --> 05:51there's pretty good population
05:51 --> 05:53level evidence that the risk of smoking
05:53 --> 05:55is first of all it's dose dependent,
05:56 --> 05:59if you smoke more and if you smoke longer,
05:59 --> 06:03that risk of developing malignancy increases.
06:03 --> 06:05On top of that,
06:05 --> 06:06when you quit smoking,
06:06 --> 06:09your risk reduction improves with time.
06:09 --> 06:11Sort of the longer ago you quit,
06:11 --> 06:14the lower your risk of developing
06:14 --> 06:16cancer goes and it sort of
06:16 --> 06:19starts to mirror the risk of the
06:19 --> 06:21general population over time.
06:21 --> 06:23So that at about 10 to 15 years
06:23 --> 06:25after you quit smoking,
06:25 --> 06:27after a patient quits smoking,
06:27 --> 06:29I tell my patients that at around
06:29 --> 06:32that time you're sort of close to the
06:32 --> 06:35baseline exposure or excuse me the
06:35 --> 06:37baseline risk of developing bladder
06:37 --> 06:40cancer as the general population.
06:40 --> 06:43So on both sides whether before
06:43 --> 06:46or after a diagnosis of bladder cancer,
06:46 --> 06:48there's still a clear indication
06:48 --> 06:50to quit smoking and
06:50 --> 06:52kick that habit if possible.
06:54 --> 06:55I tell patients in clinic
06:55 --> 06:56frequently that
06:56 --> 06:58it's so easy for me to say and it's so
06:58 --> 07:00easy to just talk about casually like this.
07:00 --> 07:01But you know,
07:01 --> 07:02I acknowledge that it's a really
07:02 --> 07:03challenging thing for them.
07:06 --> 07:07And true enough
07:07 --> 07:09it certainly is challenging,
07:09 --> 07:11but there are resources that
07:11 --> 07:13can help people quit smoking.
07:13 --> 07:15Can you talk a little bit about
07:15 --> 07:17what are some of the things that
07:17 --> 07:19you encourage patients to do,
07:19 --> 07:21whether it's
07:21 --> 07:23going to a smoking cessation
07:23 --> 07:25program or a quit line?
07:25 --> 07:28Are those resources available in
07:28 --> 07:31the community and do they work?
07:32 --> 07:34Yes, these are things that
07:34 --> 07:35I encourage patients to do.
07:35 --> 07:38We do have a smoking cessation program
07:38 --> 07:40at the hospital where I work and it's
07:40 --> 07:43really quite robust and there are
07:43 --> 07:45providers that specialize specifically
07:45 --> 07:47in helping patients achieve this goal.
07:47 --> 07:49And so one of the things that
07:49 --> 07:52we try to do is make sure to connect
07:52 --> 07:53patients to resources like this.
07:53 --> 07:56There are multiple prescription medications
07:56 --> 07:59like nicotine replacement supplements
07:59 --> 08:01which can also improve patients
08:01 --> 08:04success rates in quitting smoking.
08:04 --> 08:06On top of that,
08:06 --> 08:08especially for patients
08:08 --> 08:09who've been smoking for a long time.
08:09 --> 08:12And for them it's related to social or
08:12 --> 08:15other sort of benefits that aren't just
08:16 --> 08:18the habit alone,
08:18 --> 08:20but they have other reasons
08:20 --> 08:21that they're smoking.
08:21 --> 08:23It's sometimes helpful to talk to
08:23 --> 08:25mental health providers or other
08:25 --> 08:27practitioners who really are
08:27 --> 08:29effective at changing harmful habits.
08:29 --> 08:33So there are a lot of resources and
08:34 --> 08:36we're very lucky to have lots
08:36 --> 08:37of resources here, but most
08:39 --> 08:42major health centers have some
08:42 --> 08:44capacity to help patients achieve this goal.
08:44 --> 08:45And you know,
08:45 --> 08:47that speaks to the fact that
08:47 --> 08:50this habit is related to a lot
08:50 --> 08:51of adverse health outcomes,
08:51 --> 08:53not just bladder cancer of course.
08:53 --> 08:56And so lots of different groups in
08:56 --> 08:58the hospital and different providers
08:58 --> 09:00have a strong incentive
09:00 --> 09:03to really help patients quit smoking.
09:03 --> 09:05Yeah, absolutely. NOTE Confidence: 0.907392057692308
09:05 --> 09:08One of the questions that people may
09:08 --> 09:09ask surrounding quitting smoking
09:09 --> 09:11and the risks of various things,
09:11 --> 09:14whether it's heart disease or cancer,
09:14 --> 09:17but in this case, bladder cancer is
09:17 --> 09:20if smoking causes bladder cancer,
09:20 --> 09:23if I replace the smoking with nicotine,
09:23 --> 09:25isn't that still just a chemical?
09:25 --> 09:27And doesn't that chemical
09:27 --> 09:28also increase my risk?
09:29 --> 09:31It's a good question and
09:31 --> 09:33you know this is an especially important
09:35 --> 09:37question as we've gotten other
09:37 --> 09:40cigarette supplements like
09:40 --> 09:42electric vapes and things like this,
09:42 --> 09:43electronic vapes rather.
09:44 --> 09:45And you know,
09:45 --> 09:47the question is how does the risk
09:48 --> 09:50from those types of exposures relate
09:50 --> 09:52to the risk compared to cigarettes.
09:52 --> 09:56We don't know a lot of those answers.
09:56 --> 09:58You know, we're learning more and more
09:58 --> 10:00about the impact of some of these on the
10:01 --> 10:03lungs and some of these exposures
10:03 --> 10:06on other parts of the body that we
10:06 --> 10:08see more immediately because we
10:08 --> 10:10have shorter term data on them.
10:10 --> 10:12The risk of long term things like
10:12 --> 10:14the development of bladder cancer,
10:14 --> 10:16which doesn't happen of course
10:16 --> 10:18immediately but happens over time,
10:18 --> 10:20it's sort of a cumulative exposure and
10:20 --> 10:25risk is less well known so
10:26 --> 10:28I definitely don't recommend it to
10:28 --> 10:30patients but it's hard for
10:30 --> 10:31me to associate specific numbers
10:31 --> 10:32with those things.
10:32 --> 10:34These are things we're learning.
10:34 --> 10:36What I'll say is that it's
10:36 --> 10:39hard to imagine that these risks
10:39 --> 10:42are as bad as smoking.
10:44 --> 10:46We know so much about
10:46 --> 10:48the harms of smoking that it's
10:48 --> 10:50almost certainly a more extreme sort
10:50 --> 10:52of example of some of these risks.
10:52 --> 10:54But we don't know
10:54 --> 10:55that for sure.
10:55 --> 10:57Which brings me to other
10:57 --> 10:58occupational exposures.
10:58 --> 11:01So in addition to smoking you had
11:01 --> 11:03mentioned that there are various
11:03 --> 11:06chemicals that one can be exposed
11:06 --> 11:07to either environmentally or
11:07 --> 11:09occupationally which increases the
11:09 --> 11:11risk of bladder cancer and these
11:11 --> 11:14risks are relatively well known.
11:14 --> 11:16So then the question is,
11:16 --> 11:19how do I know if I'm in a workplace
11:19 --> 11:21or in an environment that has
11:21 --> 11:23exposure to these chemicals and
11:23 --> 11:25if it is an occupational exposure,
11:25 --> 11:27how come the government isn't banning
11:27 --> 11:30them if we know that there's a
11:30 --> 11:31strong risk with bladder cancer?
11:31 --> 11:32A lot of the
11:32 --> 11:33substances that have historically
11:33 --> 11:35been described these sort of
11:35 --> 11:37particular compounds that
11:37 --> 11:39are associated with certain dyes,
11:39 --> 11:41for example in clothing or hair
11:41 --> 11:43dyes is sort of the classic example,
11:43 --> 11:47are not commonly used anymore.
11:47 --> 11:48And so I don't
11:48 --> 11:51know the exact incidence
11:51 --> 11:53of bladder cancer associated with
11:53 --> 11:56those dyes from contemporary data.
11:56 --> 11:59A lot of these descriptions are
11:59 --> 12:02sort of data that come from
12:02 --> 12:05our more historic exposures,
12:05 --> 12:06I would say.
12:06 --> 12:07That's not to say that they
12:07 --> 12:09don't occur anymore.
12:09 --> 12:11I would say that
12:11 --> 12:12it's definitely
12:12 --> 12:15not a common thing that I see
12:15 --> 12:16clinically I should say.
12:17 --> 12:19The other risk factor that
12:19 --> 12:21many cancers have but that you really
12:21 --> 12:24haven't touched on yet and I was hoping
12:24 --> 12:27to get your thoughts on has to do
12:27 --> 12:29with genetics and family history.
12:29 --> 12:32Is bladder cancer something that,
12:32 --> 12:35if you have a family history of it,
12:35 --> 12:37it increases your own personal risk?
12:39 --> 12:40That's a good question.
12:40 --> 12:43There are certain genetic risks
12:43 --> 12:45associated with bladder cancer.
12:45 --> 12:47There's actually a related
12:47 --> 12:50malignancy to bladder cancer that
12:50 --> 12:52we talked about
12:52 --> 12:53which is ureteral cancer,
12:53 --> 12:55cancer of the ureters, the tubes that
12:55 --> 12:57drain the kidneys from the bladder.
12:57 --> 13:00That has a very clear genetic risk,
13:00 --> 13:02specifically with a disorder
13:02 --> 13:03called Lynch syndrome.
13:03 --> 13:06It's an inheritable genetic risk that's
13:06 --> 13:08associated with urothelial cancers.
13:08 --> 13:11More the ureter than the bladder.
13:14 --> 13:16The bladder cancer is
13:16 --> 13:17slightly at an increased risk
13:17 --> 13:20compared to the general population for
13:20 --> 13:22patients with this genetic disorder,
13:22 --> 13:25but definitely not as elevated of a
13:25 --> 13:29risk as in the cancer of the ureters.
13:29 --> 13:31This is an associated cancer as
13:31 --> 13:35far as whether or not having a parent
13:35 --> 13:37or siblings or first degree relative
13:37 --> 13:40with bladder cancer raises your risk,
13:40 --> 13:42the answer is it does very slightly
13:42 --> 13:44but not as much as other cancers.
13:44 --> 13:47We don't think of it as quite as inheritable.
13:47 --> 13:48That being said,
13:48 --> 13:50there's no doubt that a family
13:50 --> 13:52with a long history of bladder cancer,
13:53 --> 13:56or especially high rates of bladder cancer,
13:57 --> 13:59it does seem to increase an individual's
13:59 --> 14:01risk slightly in enough to detect
14:01 --> 14:03it in population level data.
14:04 --> 14:06Great. Well, we need to take a
14:06 --> 14:08quick break for a medical minute,
14:08 --> 14:09but please stay tuned
14:09 --> 14:11to learn more about the care of patients
14:11 --> 14:13with bladder cancer with my guest,
14:13 --> 14:15doctor Fed Ghali.
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15:31 --> 15:34You're listening to Connecticut Public Radio.
15:34 --> 15:34Welcome
15:34 --> 15:36back to Yale Cancer Answers.
15:36 --> 15:38This is Doctor Anees Chagpar,
15:38 --> 15:40and I'm joined tonight by my guest,
15:40 --> 15:41Doctor Fed Ghali.
15:41 --> 15:43We're talking about the care of
15:43 --> 15:44patients with bladder cancer
15:44 --> 15:46and before the break we spent
15:46 --> 15:48a lot of time talking about
15:48 --> 15:49what exactly is bladder cancer.
15:49 --> 15:50Interestingly,
15:50 --> 15:53it's perhaps more common than many
15:53 --> 15:56of us think, what one of the 5th
15:56 --> 15:58or 6th most common cancers we see
15:58 --> 16:00here in the US? We talked about how
16:00 --> 16:02it was associated with smoking
16:02 --> 16:06and various chemicals as well as
16:06 --> 16:08slightly related to family history
16:08 --> 16:11and some genetic syndromes.
16:11 --> 16:13But what I was hoping that now
16:13 --> 16:15we could kind of pick up the
16:15 --> 16:16conversation and talk about what
16:16 --> 16:18are the signs and symptoms that
16:18 --> 16:20people might present with when
16:20 --> 16:22they come in with bladder cancer.
16:22 --> 16:24It's not really a cancer that we screen for,
16:24 --> 16:25right?
16:26 --> 16:26That's correct.
16:26 --> 16:30We don't routinely screen for bladder cancer.
16:30 --> 16:31And just to clarify,
16:31 --> 16:35by screen we mean taking healthy
16:35 --> 16:36asymptomatic patients and basically
16:36 --> 16:39doing some tests or exams to
16:39 --> 16:41search for bladder cancer when
16:41 --> 16:44there's otherwise no good reason.
16:44 --> 16:46We don't routinely do that.
16:46 --> 16:49And it's not recommended by any of our
16:49 --> 16:51national guidelines here
16:51 --> 16:53in the United States or elsewhere.
16:53 --> 16:56And the reason is because screening
16:56 --> 16:59has both benefits and downsides and
16:59 --> 17:02the assessment of the
17:02 --> 17:05benefits and risks hasn't shaken
17:05 --> 17:07out to recommend routine screening.
17:07 --> 17:10So we don't screen for bladder
17:10 --> 17:12cancer and instead we wait until
17:12 --> 17:14there's a reason that one should
17:14 --> 17:16look for bladder cancer,
17:16 --> 17:18do a diagnostic assessment for bladder
17:18 --> 17:20cancer before we really do a work up.
17:21 --> 17:24So presumably then patients
17:24 --> 17:26who have bladder cancer would need
17:26 --> 17:28to present with some sort of symptom.
17:28 --> 17:30Can you can you talk a little bit
17:30 --> 17:31about what are the warning signs,
17:31 --> 17:33what are the symptoms that should
17:33 --> 17:35prompt people to seek medical attention
17:35 --> 17:37that might turn into bladder cancer?
17:38 --> 17:41Of course, like most cancers they
17:41 --> 17:44can present with a lot of various
17:44 --> 17:46symptoms depending how long
17:46 --> 17:48it has been there and where it is in
17:48 --> 17:50the Natural History of the disease.
17:50 --> 17:53But by and large the most common
17:53 --> 17:55symptom that a patient
17:55 --> 17:56would present with that
17:56 --> 17:58would trigger a work up for bladder
17:58 --> 18:00cancer would be blood in the urine,
18:00 --> 18:03what we call hematuria.
18:03 --> 18:05That's sort of the classic
18:05 --> 18:07presentation for bladder cancer
18:07 --> 18:09and is definitely what we see most
18:09 --> 18:11frequently in the clinic as well.
18:12 --> 18:14And sometimes people
18:14 --> 18:17when they go to the doctor just
18:17 --> 18:19for their routine physical,
18:19 --> 18:21they'll get a a urine sample
18:21 --> 18:23and sometimes when
18:23 --> 18:24we get those reports back,
18:24 --> 18:27there is a line there that says blood.
18:27 --> 18:29So even if you haven't seen
18:29 --> 18:31blood in the urine,
18:31 --> 18:34is there another way that bladder
18:34 --> 18:36cancer can be present on one of
18:36 --> 18:37these routine urine tests?
18:38 --> 18:40Yes, you're touching on an
18:40 --> 18:42important distinction here which is
18:42 --> 18:45blood that is visible,
18:45 --> 18:47that is visible to the patient
18:47 --> 18:49is what we call gross hematuria.
18:49 --> 18:51And separately what you're describing
18:51 --> 18:54for blood that's seen on just the test,
18:54 --> 18:55in other words, what I tell
18:55 --> 18:57my patients is you wouldn't have
18:57 --> 18:58known there was anything going on.
18:58 --> 19:00We told you there was blood that was
19:00 --> 19:03seen under the microscope and so on.
19:03 --> 19:05That's what we call microhematuria.
19:08 --> 19:10And the presence of either of those occurring
19:10 --> 19:14is a good reason to check
19:14 --> 19:16in with a urologist and be evaluated.
19:17 --> 19:19Now like you say, micro
19:19 --> 19:23hematuria is more common than the more
19:23 --> 19:25visible gross hematuria and it's less
19:25 --> 19:28associated with the
19:28 --> 19:30diagnosis of bladder cancer than visible
19:30 --> 19:34blood in the urine, or gross hematuria.
19:34 --> 19:35And so the work up is not always
19:35 --> 19:36exactly the same.
19:36 --> 19:38Sometimes we end up doing very
19:38 --> 19:40similar things for the work up,
19:40 --> 19:43but both at least warrant a discussion
19:43 --> 19:45about a work up for bladder cancer
19:45 --> 19:48and an assessment of other risk
19:48 --> 19:50factors like we discussed earlier.
19:52 --> 19:54And so if a patient does have
19:54 --> 19:56risk factors and hematuria,
19:56 --> 19:59or presents with gross hematuria,
19:59 --> 20:02what what does the work up look like?
20:03 --> 20:05So what I tell patients is that
20:05 --> 20:07blood in the urine doesn't give us
20:07 --> 20:09a diagnosis of cancer by any means.
20:09 --> 20:12It just makes our ears perk up a
20:12 --> 20:14little bit and sort of triggers
20:14 --> 20:16us to do more investigation.
20:16 --> 20:19And many times when we look more closely
20:19 --> 20:22we find other good causes,
20:22 --> 20:25other benign causes for blood in the urine.
20:25 --> 20:27And so there's a list of non cancerous
20:27 --> 20:29things that can cause blood in the urine,
20:29 --> 20:32which I'd be happy to discuss.
20:32 --> 20:36But once we embark on a work
20:36 --> 20:38up for blood in the urine,
20:38 --> 20:39the work up normally entails
20:39 --> 20:41a couple of things.
20:41 --> 20:44One is another urine test to ensure
20:44 --> 20:46that there's no infection of the urine.
20:46 --> 20:48So this is a common cause of blood
20:48 --> 20:50in the urine as many patients
20:50 --> 20:52or many listeners will know.
20:52 --> 20:55So we confirm that there's not an obvious
20:55 --> 20:57reason that there's blood in the urine.
20:57 --> 21:00We will also see the patient in clinic
21:00 --> 21:03and do a full history and physical will
21:03 --> 21:06understand any changes
21:06 --> 21:09in their history recently,
21:09 --> 21:12any recent trauma for example or any other
21:12 --> 21:14changes in symptoms that sort of thing.
21:14 --> 21:17We'll understand a bit of their history,
21:17 --> 21:20but ultimately we will decide to
21:20 --> 21:23do some type of imaging of their
21:23 --> 21:25abdomen in order to evaluate
21:25 --> 21:27their kidneys and often their ureters,
21:27 --> 21:29those tubes that drain the
21:29 --> 21:30kidneys down into the bladder.
21:30 --> 21:32So some type of imaging is usually
21:32 --> 21:33warranted and the most
21:33 --> 21:35common form of that is a CT scan,
21:36 --> 21:38it's a special type of CT scan called
21:38 --> 21:41ACT urogram which is a specific
21:41 --> 21:43protocol that we use that helps
21:43 --> 21:46us really clearly visualize the
21:46 --> 21:48kidney and the ureters especially.
21:48 --> 21:49It sort of allows us to zero in on
21:49 --> 21:51those parts of the body which are
21:51 --> 21:53of course would be common
21:53 --> 21:56causes of blood in the urine.
21:56 --> 21:57And finally
21:57 --> 21:59the last sort of central part
21:59 --> 22:02of a hematuria workup is a small
22:02 --> 22:05procedure that we call a cystoscopy.
22:05 --> 22:07And a cystoscopy is a procedure
22:07 --> 22:08most often done in the clinic.
22:08 --> 22:11And it's basically
22:11 --> 22:13the insertion of a small camera,
22:13 --> 22:16a small flexible camera into the urethra
22:16 --> 22:18and through the urethra into the bladder.
22:18 --> 22:20And we physically
22:20 --> 22:21fill the bladder up with fluid
22:21 --> 22:23and we look around in the bladder and
22:26 --> 22:28make sure that we don't see any lumps
22:28 --> 22:30or bumps or areas of redness or concern.
22:30 --> 22:34And we have fully just
22:34 --> 22:35looked at every little bit of the bladder
22:35 --> 22:37to make sure there's nothing
22:37 --> 22:40that warrants further treatment.
22:40 --> 22:41And so between the urine,
22:41 --> 22:43history, and
22:43 --> 22:46physical and then the urine test
22:46 --> 22:48ACT scan usually and a cystoscopy,
22:48 --> 22:50that's what we sort of think
22:50 --> 22:51of as a hematuria workup.
22:52 --> 22:54And so presumably if on cystoscopy
22:54 --> 22:58you do see a patch of redness or a
22:58 --> 23:01lump or bump that could potentially
23:01 --> 23:05make you think about a bladder cancer.
23:05 --> 23:07Can biopsies be done at the same time,
23:09 --> 23:11They can occasionally be done at
23:11 --> 23:13the same time, but that is not
23:13 --> 23:15routine to do it at the same time.
23:15 --> 23:19And the reason is that if we see
23:19 --> 23:20a lesion, something that looks
23:20 --> 23:22like a tumor of the bladder,
23:22 --> 23:25the next steps will be to
23:25 --> 23:27find out what the diagnose,
23:27 --> 23:29what the Histology of
23:29 --> 23:32that lesion is and get a
23:32 --> 23:33pathologic diagnosis and either
23:33 --> 23:36confirm or rule out bladder cancer.
23:36 --> 23:39And to do that we almost always will
23:39 --> 23:41stop the procedure
23:41 --> 23:44at that time and we will suggest to the
23:44 --> 23:46patient that we go to the operating
23:46 --> 23:50room and remove the tumor in
23:50 --> 23:52its entirety rather than just take
23:52 --> 23:54a small biopsy which will give
23:54 --> 23:57us a more successful diagnostic,
23:57 --> 23:59diagnosis rather of the specific
23:59 --> 24:02cell types and what is growing
24:02 --> 24:03under the microscope basically.
24:03 --> 24:05But on top of that we know that
24:05 --> 24:07a procedure like this where
24:07 --> 24:09the whole tumor is removed
24:10 --> 24:12it's not just diagnostic but it's
24:12 --> 24:13also therapeutic.
24:13 --> 24:15You know if there is cancer there,
24:15 --> 24:17it's really important that we remove
24:17 --> 24:19the cancer from the patient's body.
24:19 --> 24:21We get a better understanding of
24:21 --> 24:23what we're dealing with and doing a
24:23 --> 24:26a thorough resection of this tumor
24:26 --> 24:28we know that it
24:28 --> 24:29improves outcomes and decreases the
24:29 --> 24:31chance of recurrence down the road.
24:31 --> 24:32And so that's usually what we do
24:32 --> 24:34if we see something suspicious is
24:34 --> 24:36instead of a small biopsy in the clinic,
24:36 --> 24:39we will normally not put patients
24:39 --> 24:42through that and instead say you know
24:42 --> 24:44there really shouldn't be a
24:44 --> 24:45whole lot growing on the inside of
24:45 --> 24:47your bladder except with
24:47 --> 24:49really rare exceptions if there's
24:49 --> 24:51something on the inside of the bladder,
24:51 --> 24:52we usually would like to
24:52 --> 24:54remove it in its entirety.
24:55 --> 24:57So a couple of questions on that.
24:57 --> 25:01One, what's the breakdown between how
25:01 --> 25:04many of these lesions turn out to
25:04 --> 25:06be completely benign versus how many
25:06 --> 25:09actually turn out to be a bladder cancer?
25:09 --> 25:11And #2, can you kind of illustrate
25:11 --> 25:13for us a little bit more about what
25:13 --> 25:16you mean by a complete resection?
25:16 --> 25:18Do you mean removing a portion
25:18 --> 25:20of the bladder wall or do you
25:20 --> 25:21mean removing the whole bladder,
25:22 --> 25:23which might be kind of scary
25:23 --> 25:24for some patients?
25:25 --> 25:26Thank you. Yeah,
25:26 --> 25:28that's a really important distinction.
25:28 --> 25:31Let's talk about that.
25:31 --> 25:33There are certain benign things
25:33 --> 25:35that can grow in the bladder.
25:35 --> 25:37There are certain types of inflammatory
25:37 --> 25:40lesions or you know certain benign
25:40 --> 25:43almost polyp like lesions that can grow.
25:43 --> 25:45And I would say
25:45 --> 25:47I don't have off the top of my head
25:47 --> 25:50a breakdown of the number that is
25:50 --> 25:52malignant and the number that is benign.
25:52 --> 25:55But it's not an insignificant
25:55 --> 25:58number where we go into the bladder and
25:58 --> 26:01we see what looks like a small growth or a
26:01 --> 26:03little something like a cyst in the bladder.
26:03 --> 26:05And when we look at it under the microscope,
26:05 --> 26:08we find that it was some inflammatory
26:08 --> 26:11change or something that wasn't cancer.
26:11 --> 26:14That being said many and I would
26:14 --> 26:16say most growths in the bladder
26:16 --> 26:18that we see grossly we can,
26:18 --> 26:20especially urologists that
26:20 --> 26:22see this type of thing frequently,
26:22 --> 26:25I can have a have a pretty good sense,
26:25 --> 26:27I can look at a bladder,
26:27 --> 26:29lesion and
26:29 --> 26:30really know with some confidence
26:30 --> 26:33whether or not this is a concerning
26:33 --> 26:35type or more of an inflammatory type.
26:35 --> 26:37And that's sort of the trigger is
26:37 --> 26:38the gross appearance of the lesion.
26:38 --> 26:40If it's suspicious enough that's
26:40 --> 26:43the trigger for doing this more
26:43 --> 26:45involved procedure.
26:45 --> 26:46So let me tell you a little
26:46 --> 26:47bit about the procedure.
26:47 --> 26:48That is the most common procedure
26:48 --> 26:50we do for this type of thing,
26:50 --> 26:52at least initially it's a
26:52 --> 26:54procedure called the transurethral
26:54 --> 26:56resection of a bladder tumor or TURBT.
26:57 --> 26:58It's a bit of a mouthful.
26:58 --> 27:00And what this procedure is,
27:00 --> 27:03we basically go under
27:03 --> 27:05anesthesia in the operating room.
27:05 --> 27:07We use a camera, not unlike the one
27:07 --> 27:09that's used in clinic except it's a
27:09 --> 27:11little bigger and more sophisticated,
27:11 --> 27:13and allows us to do more procedures
27:13 --> 27:14through the channel of the camera.
27:14 --> 27:16So we're not making incisions,
27:16 --> 27:18we're not cutting out parts of the bladder,
27:18 --> 27:21but instead are using an instrument,
27:21 --> 27:25an endoscopic instrument that's minimally
27:25 --> 27:28invasive meant to hopefully cause the
27:28 --> 27:31least discomfort and morbidity for patients.
27:31 --> 27:33And we go to the operating room and
27:33 --> 27:35pass that again through the
27:35 --> 27:36urethra,
27:36 --> 27:39the channel into the bladder and through
27:39 --> 27:42that instrument we're able to sort of in
27:42 --> 27:45a piece meal way remove
27:45 --> 27:47this suspicious lesion.
27:47 --> 27:48We don't remove part of the bladder.
27:48 --> 27:50We remove the tumor and then we
27:50 --> 27:53will try to remove some of the
27:53 --> 27:55underlying bladder in order to
27:55 --> 27:58get to basically to get an answer
27:58 --> 28:00to the question of how advanced,
28:00 --> 28:01if this is a cancer,
28:01 --> 28:03how advanced is this cancer
28:03 --> 28:04into the wall of the bladder.
28:04 --> 28:06And that ends up being a very
28:06 --> 28:07important question for deciding
28:07 --> 28:09next steps for treatment, is what
28:09 --> 28:11we call the stage of the disease,
28:11 --> 28:13which if there is a cancer,
28:14 --> 28:15is this cancer early stage
28:15 --> 28:17in that it's on
28:17 --> 28:20the surface of the bladder or is
28:20 --> 28:22this more advanced requiring you
28:22 --> 28:23know having advanced deeper into
28:23 --> 28:25the wall of the bladder.
28:25 --> 28:28And and the answer to that
28:28 --> 28:31question really helps us decide
28:31 --> 28:33the best therapy moving forward.
28:33 --> 28:35Doctor Fed Ghali is an
28:35 --> 28:36assistant professor of urology
28:36 --> 28:39at the Yale School of Medicine.
28:39 --> 28:41If you have questions,
28:41 --> 28:43the address is canceranswers@yale.edu,
28:43 --> 28:45and past editions of the program
28:45 --> 28:48are available in audio and written
28:48 --> 28:49form at yalecancercenter.org.
28:49 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public Radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

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Bladder Cancer: Beyond the Statistics with guest Dr. Fed Ghali February 25, 2024