Bladder cancer is the 4th-most common cancer among men, but when detected early, it can be managed and often cured. Dr. Lambros Stamatakis discusses how we find and treat this disease, and what we do if it comes back.
TRANSCRIPT
Intro: MedStar Washington Hospital Center presents medical intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. In today's episode, we talk to Dr. Lambros Stamatakis, Director of Urologic Oncology at MedStar Washington Hospital Center about bladder cancer. Dr. Stamatakis discusses bladder cancer symptoms, how treatment has advanced over the years, including techniques unique to MedStar Washington Hospital Center and what patients can expect during treatment and recovery.
Host: Thanks for joining us today.
Dr. Stamatakis: Thanks for having me.
Host: So, let's get started on bladder cancer. How common is it, what do people need to know?
Dr. Stamatakis: So, bladder cancer is often considered a bit of an orphan cancer because it doesn't get as much press as some of the other cancers out there. But it's actually the fourth most common cancer in men. So if we compare this to prostate cancer, there's about 160,000 new cases estimated to occur in 2017, bladder cancer we're estimating around 60,000 to 65,000 in men. So, it's a relatively common cancer in men, overall about 78,000 cases a year. So, it's less common in women and the reason for that is a bit unclear, but it is something that we predominantly see in men.
Host: And how common is it in the D.C. area? How many cases do you see in a month or year?
Dr. Stamatakis: Estimates from the National Cancer Institute suggest that there are around 3,000 total new cases in the D.C. metropolitan area, so I'm including Maryland and Virginia in those numbers. I usually, because I am a referral center for bladder cancer, I often see around 10 to 20 cases a month. We do more bladder cancer than any other institution in the District of Columbia. So, being a high-volume center, we're very experienced in the nuances of the surgical treatment of this disease, which is paramount for how you manage bladder cancer. Because of that, we also have higher expertise in knowing how to stage the disease and also how to manage it moving forward. We also have a multidisciplinary clinic where surgical folks like myself work with medical oncologists and our partners from Lombardi Cancer Institute over at Georgetown to provide systemic therapy in patients that need it or require that. Also, again, clinical trials are another option for some of our patients who are interested, and that can provide therapies that are not otherwise available as standard-of-care yet.
Host: And, what are the most common symptoms?
Dr. Stamatakis: So, blood in the urine is the number one symptom that typically prompts referral to a urologist. Blood in the urine can also be caused by other benign conditions. For example, somebody having a kidney stone or an enlarged prostate. But for the urologists, we need to make sure that we rule out bladder cancer or other malignant causes of blood in the urine. So that's certainly something that most of our patients won't present with, but not all. Other patients can have irritating voiding symptoms, meaning they're going to the bathroom more frequently or they're having a sense of extreme urgency and that's not getting better with the traditional therapies that we give for those types of symptoms. Every once in a while now, with modern day imaging, we're also able to pick these things up incidentally. So, a patient gets a cat scan for another reason and the radiologist sees a little tumor in the bladder that then prompts the referral to us.
Host: So typically, when somebody comes in and they had blood in their urine, is that a sign that it's usually already advanced a little ways?
Dr. Stamatakis: Not necessarily. Not necessarily. But what it will signal to the urologist is that a specific workup needs to be completed. So, that includes getting imaging of the kidneys and upper urinary tract, so that includes the tubes that connect the kidneys to the bladder, called the ureters. And that's most typically done using a CT scan and specifically something called a CT urogram. In addition, a cystoscopy will often be offered to the patient and that's a procedure where we stick a small camera inside the patient's bladder to directly visualize the surface of the bladder; make sure that they don't see anything that's abnormal.
Host: And, most bladder cancers are diagnosed relatively late though, correct? Or …
Dr. Stamatakis: Not necessarily. About 75 percent of them actually are present in the quote non-muscle invasive state. So, that's a big differentiator when we talk about bladder cancer staging is whether the disease is muscle invasive or non-muscle invasive. And, to go back a little bit, the bladder is essentially a muscular sac that just stores urine. The bladder itself has multiple layers and these cancers derive from the inner layer of the bladder, known as the urothelium. So as these tumors grow, they tend to grow from the urothelium towards the outside of the bladder. And right sandwiched in between is the quote muscle or detrusor muscle of the bladder. So, when we see a bladder tumor on a cystoscopy on somebody who's been worked up for blood in the urine, the next step will be to take them to the operating room to resect that tumor. That procedure will accomplish two goals. Number one, it's diagnostic, so we get it out, the pathologist does their exam under the microscope, tells us what it is and how deep it's invading into the bladder. And then the second thing is that it's potentially therapeutic. So if it's non-muscle invasive, often we can then watch those patients very closely and may offer select patients intravascular therapy, which basically means different types of drugs inside the bladder to prevent further recurrence or treat any remaining microscopic disease that's left behind. If it's muscle invasive, then we're a little bit more aggressive.
Host: And how has bladder cancer treatment, how has it advanced over the years?
Dr. Stamatakis: In many different ways. Initially, the treatment of bladder cancer, or traditionally, has, for muscle invasive disease, has been removal of the entire bladder with a urinary diversion. And a urinary diversion basically means being able to figure out a way to somehow get the urine out, for that particular patient. The most common thing that's done in the United States is something called an ileal conduit urinary diversion, or otherwise known as a urostomy, where, essentially, we plug the kidney tubes into a small piece of intestine which then gets tunnelled through the abdominal wall and creates a small stoma, and the urine will then basically drain into a bag. But as time has gone on, we've now developed other methods for urinary diversions. We can even create what's called a neobladder, using a much longer piece of intestine but being able to connect that pouch that we create to the patient's native urethra, so then they can basically void through their natural orifice. So, that does help to prevent the need for an external appliance and is more cosmetically pleasing for select patients. In addition, another thing that's really changed is the kind of something that I eluded to before, was a multidisciplinary approach to treating these cancers, and that is no better highlighted than in the use of chemotherapy up front before radical surgery for these conditions. In a big randomized control trial done by the Southwest Oncology Group in the early 2000s, getting upfront chemotherapy actually was shown to confer an overall survival advantage compared to patients who went to cystectomy directly or bladder removal directly. So, that is something that we do offer all of our patients, upfront chemotherapy, and ultimately, hopefully, be able to confer that survival advantage for them. One thing that we do differently is something called blue light cystoscopy. Blue light cystoscopy is an enhanced cystoscopic technique and essentially what it involves is the administration of a dye into the bladder about an hour prior to going back to the operating room for a bladder biopsy. And what will happen is that this dye essentially gets preferentially retained within the cancer cells as opposed to the normal bladder tissue.
So, when we shine a specific wavelength of light, which looks blue, the areas of abnormality will appear to fluoresce. It almost looks like a fluorescent pink little spot on the screen. So, the benefit is that—is several. First off, we are able to identify tumors that otherwise you may miss on traditional cystoscopy. And it's not that you have a bad urologist that misses it, it's just the fact that some of these lesions can be so small that they're really hard to perceive with the naked eye. In addition, when you have a tumor in place, we have a theory that when you end up excising that tumor through that procedure that perhaps you may be leaving some tumor behind. So, using this technique, we can actually evaluate the edges of the tumor resection site and make sure that we got everything out. And, if we need to, we resect a little bit more to make sure that we have a negative margin, meaning that we got all the tumor out as we possibly can. So, this doesn't really add that much to the patient experience, other than the fact that they have to have this dye put inside their bladder about an hour before, and we really feel that it adds an additional piece of information to us when we're making the diagnosis and performing these procedures for these bladder tumors.
Host: When a patient comes in, what should they expect?
Dr. Stamatakis: So, again, I'll kind of break this up into sort of the non-muscle invasive and the muscle invasive group. So, in patients with non-muscle invasive, otherwise known as superficial, bladder cancer, the one thing that patients need to understand is that recurrence is unfortunately the rule with bladder cancer. These tumors, depending on the stage and the grade, which is something that's determined by the pathologist, the recurrence rates can be quite high. So, in order to identify those recurrences, we have to routinely perform cystoscopies, again looking inside their bladder, to be able to identify those recurrences early. So, a patient that is being treated for non-muscle invasive bladder cancer needs to realize that they're going to be getting occasional procedures to look inside their bladder. And often that can be just done in the office as an outpatient procedure with relatively little discomfort to the patient, if any at all. In addition, there are multiple therapies that we use inside the bladder to, again, in certain patients, to help prevent these tumors from coming back. In patients with muscle invasive disease, again, that's when we get our multidisciplinary folks involved and we'll have them work together with our medical oncologists to select a therapy that's personalized to their particular disease state and also for their preferences. And often we will offer radical surgery, and, when it's appropriate, do it through a minimally invasive approach. I typically use the DaVinci robot for bladder removal, and that's something that will be offered to many of our patients in our practice. So, those are the sort of, the things that we, that we end up offering to our patients.
Host: What can a survivor expect during recovery and beyond?
Dr. Stamatakis: So, after radical surgery for bladder cancer, again for muscle invasive or locally advanced disease, the surgery itself is a big surgery. I mean, usually, typically, four to five days in the hospital and often it can be several months before they feel really back to normal. And after that, we will be very vigilant about performing imaging studies to make sure that their bladder cancer doesn't come back. If they have not received chemotherapy up front, we may offer it to them after the surgery, depending on the results from pathology from the bladder removal. And that's something, again, that we'll get our medical oncologists involved with. For non-muscle invasive bladder cancer, again, it's really just being vigilant about seeing each other over and over again and making sure that they get the surveillance that they need with periodic cystoscopies.
Host: As a final thought, maybe, with bladder cancer being so prevalent, why do you think it's not top-of-mind as much as other cancers?
Dr. Stamatakis: Yeah. Well, again, it hasn't gotten as much press and also, I think, because the symptoms that we discussed that are associated with bladder cancer are the same symptoms that patients often get with many benign urologic diseases. Again, if somebody has blood in the urine, the first thought to a primary care provider isn't bladder cancer. It's "Is the patient having a kidney stone? Do they have a urinary tract infection?" And often, I think our primary care providers don't like to jump to conclusions because you don't want to create fear within your patients. We see this a lot in women. Women are more prone to urinary tract infections. They'll come to their doctor and have blood in the urine and they'll treat them for a urinary tract infection almost reflexively. And the blood keeps coming back, and they keep throwing different antibiotics at them. It's often part of the reason why, despite the fact that bladder cancer occurs less frequently in women, it actually presents at a more advanced stage in women compared to men. And that's because, we think, that primary care providers often will be misdiagnosing them.
So, it is something that I think, from our perspective as educators, to be able to educate the future generations of primary care physicians to understand the appropriate workup for blood in the urine and I think that will help to increase awareness. The other thing that's also changed is that there's more advocacy groups out there now, particularly something called the Bladder Cancer Advocacy Network, that actually started in the D.C. metropolitan area. They are now doing a lot to increase awareness of bladder cancer and become advocates for patients and their families. And that's something that never really existed before and we've really been following suit and the folks that have created these sorts of organizations for prostate cancer and breast cancer, which are really the more popular, or more well-known, cancers out there. So, we're hoping that bladder cancer is going to become something that, really, people know more about as time goes on.
Host: Great. Thank you so much for joining us.
Dr. Stamatakis: Yeah, no problem. Thank you so much.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.
