Ask Us Anything About… Bladder Cancer

Scott Gilbert – From Penn State Health, this is Ask Us Anything About Bladder Cancer. I’m Scott Gilbert. Well, the symptoms of bladder cancer can mimic some other even less serious medical conditions. Yet, it is relatively common with some 80, 000 cases diagnosed each year in the US and about 17,000 deaths, unfortunately. The good news though, bladder cancer can often be detected early and there are many treatment options. And here to talk with us about all of this is Dr. Matthew Kagg. He’s a clinical vice chair at the Department of Urology at Penn State Health, Milton S Hershey Medical Center. Dr Kaag, it’s great to have you with us this afternoon. Thanks for making the time. You know, I can’t help but realize that bladder cancer combines a couple different things that we don’t like to talk about. First of all, cancer, and second of all, that part of the body. I mean, there is kind of a stigma around this cancer, right? And I imagine that makes it tough for some people to bring up the symptoms even with their doctors.

Dr. Matthew Kaag – Yeah, Scott, I think that’s very true. I don’t usually see patients coming into my clinic excited to talk to me about this. And I think the best way for us to break through that is by talking about it. The more we normalize the conversation, the more we talk about it on forums like this, the easier it is for patients to come in and bring up these concerns.

Scott Gilbert – Sure. So, what are some of the most common symptoms of bladder cancer? And I’m curious if some of them could be perhaps mistaken for other perhaps even less serious illnesses. And I see that Christie already is in the comment section asking us for some early warning signs of this type of cancer.

Dr. Matthew Kaag – Well, the most common one is blood in the urine. So, most patients will come in complaining that they’ve seen red urine for a period of time. The biggest issue that we run into is a lot of primary care doctors, a lot of patients in the community, when they see that, the first thing they think of is a urinary tract infection. This is particularly an issue with female patients, where urinary tract infections are pretty common. But bladder cancer is a disease of older people, and, you know, older men can develop urinary tract infections as well. So, unfortunately it’s sort of a sad commentary, but a lot of my patients come in where doctors, well-meaning physicians, have been treating urinary tract infections with antibiotics for sometimes a long period of time with no improvement, and what the patient really has is a tumor. And so, it’s important to sort of change the perception and help people understand that there might be something else going.

Scott Gilbert – Because I understand statistically, women are often diagnosed with bladder cancer at a later stage of disease than men, correct?

Dr. Matthew Kaag – So, most of my patients are male. About three-quarters of the bladder cancer population are men, but women do tend to be diagnosed later, simply because of this issue. A lot of physicians seeing a female patient with blood in the urine think UTI and go that direction for a period of time, and sometimes the diagnosis can be delayed because of that.

Scott Gilbert – So, how important is early detection when it comes to bladder cancer being treatable, you know, perhaps even curable.

Dr. Matthew Kaag – So, it’s very important. A lot of these tumors start out as small and fairly superficial masses. The bladder’s got multiple layers to it. The innermost layer is the watertight layer that keeps the urine on the correct side of the bladder and doesn’t allow it to leak out into the rest of the body. And that’s where these tumors start. But like the weeds in your garden, as they get bigger, they start to put down roots that go deeper and deeper. And by the time those roots get into the muscle layer of the bladder — which is the second or third layer — then they have access to vessels in the lymphatic channels that they can use as a highway to spread around the body. So, by catching those tumors at an early stage before they’ve gotten deep into the bladder wall, we’re able to preserve patients’ bladders. Once the disease is into the muscle layer, most of those patients are going to have to undergo bladder removal.

Scott Gilbert – You’re watching Ask Us Anything About Bladder Cancer from Penn State Health. I’m Scott Gilbert, alongside Dr. Matthew Kaag. He’s clinical vice chair in the Department of Urology at Penn State Health, Milton S Hershey Medical Center. And he welcomes your questions in the comment section. Feel free to just add those here, whether you’re watching this live or even if you’re watching it on recording or playback. We’ll make sure we get answers to you for any questions you have about this disease. You know, Dr. Kaag, you mentioned earlier that this tends to be an illness that’s found in older people. Bladder cancer does have a higher median age of diagnosis compared to other cancers. Why is that? Do we know?

Dr. Matthew Kaag – So, for a lot of patients, it’s a disease of exposure. It’s a cancer of exposure. And the longer patients are exposed to cancer-causing agents, the the higher the chance of developing the disease. And so in this case, these are patients, usually smokers — about 60 to 75% of my patients are either ex-smokers or current smokers. And all that stuff that we suck in through our lungs gets processed through the body and comes out in our urine, where it sits in the bladder until we urinate. And so, the bladder gets a nice healthy dose of all of those toxins. And over time, the changes to our DNA that prompt cancers to form build up. But it takes time. And so the mean age of diagnosis is somewhere around 72 or 73 years old. And it’s one of the oldest — it’s a cancer with one of the oldest mean ages of diagnosis.

Scott Gilbert – Very interesting. We have a question now from Christy. She’s asking, how do we go about getting our bladder checked, and how often should we get it checked? So I guess this speaks to the testing. You know, should people seek out testing for bladder cancers starting perhaps at a certain age, or if they are a smoker?

Dr. Matthew Kaag – That’s a very good question. So, right now, we don’t recommend screening for bladder cancer. What screening is testing like mammography for breast cancer, where all women of a certain age should undergo a mammogram and a breast self-exam. We do much the same thing for prostate cancer, where at a certain age, a lot of men are recommended to have a digital rectal exam and a PSA — that’s a blood for prostate cancer. We don’t have that sort of testing for bladder cancer, for a couple reasons. The testing is somewhat invasive and the cancer is fairly rare. So, what we advise patients to do is keep an eye out for symptoms. It’s blood in the urine that you’re looking for. Sometimes, more rarely, patients will complain of urinary urgency or frequency where they’re running to the bathroom very frequently. And generally what the algorithm looks like is the patient presents to their primary care doctor, gets a urine test for urinary tract infection, and when that comes back negative, saying that there’s no infection present, then the patient gets referred on to a urologist. And the testing at the urologist office involves a procedure called a cystoscopy, where we put a little flexible camera into the bladder through the urinary opening. There’s no incision. It takes about 90 seconds. The patients feel like they have to urinate really badly for that amount of time. It’s a very mildly uncomfortable procedure for most patients. And that gives us a look at the entire inside of the bladder. We’ll usually couple that with a CAT scan so that we can look at the outside of the bladder and the kidneys as well. And so that’s the general thought process, the general plan when we see a patient like this.

Scott Gilbert – Sure. We’ve talked a little bit about some of the risk factors and causes of bladder cancer. Interesting question from Lauren here, asking if you can get bladder cancer from holding your bladder, holding the urine in too long.

Dr. Matthew Kaag – So generally the answer is no, with a few exceptions. So there’s one specific type of bladder cancer that we see forming in patients that have chronic urinary tract irritation, particularly in patients that have had long-term catheters in place — those drainage mechanisms for their bladder — and sometimes in patients that have had really chronic, difficult courses with urinary tract infections. But as a general rule, holding the urine, while it can cause other issues, does not cause cancer.

Scott Gilbert – You’re watching Ask Us Anything About Bladder Cancer from Penn State Health. We welcome your questions for Dr. Matthew Kaag. Some great questions already. So, please do keep those coming here. Let’s turn to treatments. I mean, how do you help patients understand the risks and benefits of the various types of treatments? Because I understand it’s not cut and dry. It’s not like there’s a single course of treatment for everyone who’s diagnosed with bladder cancer, correct?

Dr. Matthew Kaag – Sure. So, the easiest way to talk about treatments is actually to split bladder cancer into two separate groups, and they’re fairly distinct: the patients that have muscle invasion and then the patients that don’t. So, if it’s okay with you, I’ll take the non-muscle invasive group first, because that’s a little simpler.

Scott Gilbert – Sounds good to me. And if you want to talk a bit about what that means. You’re talking about some of the muscles around the bladder, I imagine, and the cancer reaching those?

Dr. Matthew Kaag – Sure. So, the bladder — the third layer of the bladder — your bladder actually has four layers. And the third layer of the bladder, one of the deeper layers, is the muscle layer. That’s what allows the bladder to contract and push the urine out. And so, that layer also is full of blood vessels. And once the disease reaches that layer, once the the disease puts roots down into that layer, then we’re talking about chemotherapy, bigger surgeries that require removal of the bladder. So, let’s talk about the patients that haven’t progressed that far just yet. 75% of the patients that come into my clinic have non-muscle invasive disease. In other words, the cancer is still on the surface of the bladder. Those patients undergo a scope procedure as their diagnostic procedure, like we just talked about, the flexible scope into the bladder that allows us to look around the bladder and find the tumor. And then usually in a separate sitting, we’ll put the patient to sleep and we put a much bigger scope into the bladder, again, through the urinary opening. So, there’s no incision. And we use a small, electrified wire. It looks a little bit like an ice cream scoop, to scoop the cancer actually out of the bladder wall, and we evacuate all the pieces. Most of those patients will then go on to a variety of different medical treatments that we can place in the bladder usually over a period of several weeks that helps us prevent the bladder cancer from coming back. We look at the specimen, what we take out of the bladder, and that’s what allows us to determine whether or not there’s actually cancer invading into the muscle or not.

Scott Gilbert – Let’s talk a bit about prognosis. And I think Wayne’s question is a great way for us to go into that, in terms of he’s asking about bladder cancer with muscle invasion, whether it has a high cure rate. How does the cure rate for that type differ from others?

Dr. Matthew Kaag – So, it’s a really good questions. So, if we treat muscle invasive bladder cancer according to the current regimens that are recommended by people like the American Neurologic Association, we can achieve cure rate somewhere around 65 or 70% as a general rule. The patients that aren’t treated actually do very poorly. And muscle invasive bladder cancer that’s just left to its own devices has an overall survival rate of anywhere from a year to two and a half years. And patients are usually highly symptomatic. So, we’re actually very aggressive about offering treatment for those people.

Scott Gilbert – Sounds good. Thanks a lot for the question, Wayne. Thanks to everybody for the questions so far. Feel free to keep those coming in the comment section here below this Facebook post. What about radiation and chemotherapy? I know you talked about surgery being needed, and I think you hinted at sometimes there is a need for radiation and chemo in some cases, right?

Dr. Matthew Kaag – Yeah. So, in people that have muscle invasion, those folks are generally going to get a short course of chemotherapy followed by removal of the bladder, or in some cases, radiation. We use radiation for patients that are highly motivated to retain their native bladder. And there’s some risks involved with that, because the bladder is, you know, as long as it’s in the patient, there’s a chance that the disease can come back there. So, those patients have to be very carefully selected if we’re going to do what’s called bladder preservation with radiation. Radiation also plays a role in patients that are either too old or too sick to go through big operations like removal of the bladder, or in patients where the disease has progressed to a point where the bladder can’t be removed. The cancer has grown into surrounding structures, surrounding organs or blood vessels, and it’s not safe to operate in those patients’ pelvis, and then radiation comes into play there as well.

Scott Gilbert – And for patients who have their bladder fluid removed, are they sometimes on a catheter for an extended period of time after that?

Dr. Matthew Kaag – We try really hard to avoid that. So, patients that have their bladders removed have a couple different options for how they can be reconstructed. The most common one, at least common in the US, is for us to give that patient an external bag. That’s a bag that sits on the abdominal wall. There’s an opening fashion. The urinary tract is attached to the abdominal wall, and the urine drains constantly into that bag. The bag is then emptied into the toilet when it gets full, and that’s how the patient lives. And that’s permanent. But there’s no catheter required. There’s nothing from the outside that has to go into the patient. And people are actually very functional that way. The other options, which many people find more attractive from a cosmetic standpoint, would be things like what we call a neobladder, where we take a long segment of the patient’s intestines and basically quilt them together into a new pouch, a new bladder that can be then placed down in the pelvis and stitched into place. Those patients have a catheter in place usually for a couple of weeks while the pouch heals. And once that’s removed, the majority of those folks will urinate normally.

Scott Gilbert – Sounds like there are a lot of options, and that’s the bottom line, an important one too. Because when we talk about bladder function, we think about quality of life issues a lot, right? And the kind of function we can have going forward. So, I imagine you and your team work hard to find the best option for each patient. It’s like we said before, it’s not a standard course of treatment for every single person, it’s different.

Dr. Matthew Kaag – Correct. The counseling aspect of this is really important, and it’s one of the things that drew me to bladder cancer specifically. There was a really nice research paper that was published probably two decades ago now that showed very clearly, patients that feel like they’ve been well counselled and got to make their own decision, they’re generally happy with the decision that they’ve made and have a good quality of life. Folks that feel like they got strong armed into something or didn’t understand what they were getting into, they’re often not happy. And so it’s incumbent upon us as physicians to make that our patients understand exactly what they’re getting themselves into.

Scott Gilbert – Again, you’re watching Ask Us Anything About Bladder Cancer from Penn State Health. Dr. Matthew Kaag is clinical vice chair of urology at Penn State Health Milton S Hershey Medical Center. We’ve got some great questions for him already. And we welcome any questions you may have. Just add those to the comment field, and we make sure that we get to those. What about clinical trials and research? I mean, I know that there are some active clinical trials happening right here at Penn State Health. So, I mean, there’s another example of some options that exist for people with regard to treatment, right?

Dr. Matthew Kaag – Absolutely. The most exciting one that we probably have going right now is one that was designed right here. All of the groundwork was laid here at Penn State. And it’s currently being run nationally, but it’s a Penn State trial. We’re looking at some of the newer medications. A lot of viewers may have seen things about immunotherapy on the news. This is definitely one of the hot new topics in cancer treatment. It turns out, the body’s immune system does a really pretty amazing job of keeping these cancers in check. And if we help it along, it actually is a very effective treatment. We’re looking at ways that we can couple that with radiation therapy and try to treat patients who are not eligible to have their bladders removed. It’s a lot more tolerable than some of the older chemotherapies that we give. And patients who are sicker and older — and a lot of these patients are older and sicker — are able to tolerate it a lot better.

Scott Gilbert – That is so interesting that immunotherapy is being used for such a wide range of cancers these days. And it’s great to know that that’s available locally here. We have a question now from Amanda. She’s asking which option has the higher success rate for cancer not coming back? She says she went with the bag back in January up at Hershey. Assuming she means catheter bag, I believe. Or does she mean perhaps something created internally like you described, kind of the creation of a new bladder as it were?

Dr. Matthew Kaag – So, most patients when they talk about going with a bag, that means an external bag, what we call an ostomy or a stoma. She had an operation, I would imagine, that she had an operation called an ileal conduit, where we take a short piece of the intestine and use it kind of like the gutter on your house. We attach the kidneys to one end and we bring the other end out to the skin, and the urine drains that way. The reconstruction doesn’t dictate so much how the patient does in terms of the cancer not coming back. There’s caveats to that. But I would say that’s in general a safe thing to say. It’s really a question of how is the cancer dealt with, whether it’s radiation or whether it’s surgery. The current gold standard in this country is still surgery. And that is felt to give the patient the best chance of the disease not recurring. So what Amanda had done I would say is is probably, you know, it would be considered gold standard, and it would give her an excellent chance of being disease free.

Scott Gilbert – And when we talk about the likelihood of cancer coming back, does it apply with bladder cancer that some forms of it are more aggressive than others, as we see with other types of cancer?

Dr. Matthew Kaag – Yeah, that’s absolutely true. Fortunately, the really aggressive types tend to be more rare. But there are a couple of subtypes. There’s a neuroendocrine one that mimics some immature neurologic components. The squamous subtype, which looks a little bit like skin cancer under the microscope. Those are bad actors, and we’re really aggressive with how we treat those. But they do have a tendency to come back. Standard run-of-the-mill bladder cancer is I would say moderately aggressive. And that’s evidenced by, you know, the earlier question of how often are we successful, and I said 65 to 70% of the time. Our cure rates aren’t 100%, but we do reasonably well for what is a moderately aggressive cancer.

Scott Gilbert – And so just to bring things back to where we started then, let’s talk, remind people one more time of some of those key symptoms. Blood in the urine is a key one, right?

Dr. Matthew Kaag – Correct. Yeah, that’s the main one. Generally, blood that the patient can see. We will also work up what we call microscopic hematuria. That’s microscopic blood in the urine that the doctor might pick up on like a urine dipstick. But the big one is visible blood in the toilet, often coupled with urinary urgency or urinary frequency where the patient feels like their bladder just doesn’t hold that much anymore. These are all things that should prompt a workup by a urologist.

Scott Gilbert – And as you mentioned, a pretty high success rate in your clinic too, and we’ve got some good success stories. We’ll share at least one of those, a nice video story about one of our patients in the comment section below this Facebook post. And we’ll also share some contact information for the Department of Urology. Because it is safe to say that Penn State Health urologists see patients at Hershey Medical Center, but also on the West shore at Holy Spirit Medical Center, and in Redding at Saint Joseph Medical Center. So, a lot of options for treatment for all things urological across the health system. And a lot of great information today from Dr. Matthew Kaag. Thanks so much, Dr. Kaag, for your time.

Dr. Matthew Kaag – My pleasure, Scott. Thank you.

Scott Gilbert – All right, and thanks so much to all of you for watching Ask Us Anything About Bladder Cancer from Penn State Health.