Bladder cancer is the fourth most frequent cancer in men. However, research into the disease has been slow. The newly appointed director of the world’s only research center devoted exclusively to bladder cancer discusses risks and treatments.
Dr. David McConkey, Director, Urological Research, M.D. Anderson Cancer Center and new Director, Johns Hopkins Greenberg Bladder Cancer Institute
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16-21 BLADDER CANCER
Nancy Benson: The body’s urinary system doesn’t get much respect. But it has an important job, filtering out toxins and waste products from the bloodstream, then transporting those out of the body. With a job like that, the urinary system is exposed to a lot of substances that can do us harm. And that brings consequences–for example, bladder cancer. About 75,000 Americans are diagnosed with bladder cancer every year, and 15,000 people die of it. But some people are much more likely to develop bladder cancer than others.
Dr. David McConkey: It’s about three times, maybe even four times, more common in men than it is in women. The problem, though, is that women get a more serious disease. It’s a more aggressive disease in women.
Benson: That’s Dr. David McConkey, Director of Urological Research at the MD Anderson Cancer Center and newly appointed Director of the Johns Hopkins Greenberg Bladder Cancer Institute. It’s the world’s only institution dedicated solely to research and treatment of bladder cancer, the fourth most common cancer among men.
McConkey: Male hormones, androgens, seem to contribute to the growth of bladder cancer and so that has been studied mostly in good studies in epidemiological cohorts but also in animal models in the laboratory and so if you actually purposefully modulate the androgen receptor you can decrease bladder cancer incidence in these models, so we’re pretty sure that testosterone receptor actually contributes to bladder cancer growth.
Benson: Men may also be more likely to work in industrial jobs that put them in contact with toxic chemicals, another bladder cancer risk factor.
McConkey: Another risk factor that’s been suggested is exposure to certain metals in the environment. So, arsenic is high on the list of candidates. Others may be also involved. Exposures to these metals can be through occupations, certainly people who are exposed to metals in mines and things like that but also through environmental contaminants. So again, the idea is that passing through the body, they transit through the bladder and maybe in those people who don’t drink enough water and so there’s a longer time that those chemicals may be in the bladder before they’re eliminated that they cause problems either directly through DNA damage or through, maybe indirectly by causing inflammation.
Benson: McConkey says the link is unproven between bladder cancer and drinking too little water. It’s also an unproven link that genetics are involved.
McConkey: We think there’s a familial component to bladder cancer just as we know now that certain women are predisposed to breast cancer through genetic inheritance. But the research on bladder cancer is behind the research on breast cancer. We’re hoping that situation changes with growing awareness of the importance of bladder cancer and also we hope to kind of leverage the work that’s gone on in breast cancer now that we know that the two diseases are actually kind of similar.
Benson: Most commonly, the first bladder cancer symptom that gets people in to the doctor is blood in the urine. But McConkey says a lot of other disorders could also be to blame.
McConkey: Most often, blood in the urine does not mean bladder cancer. It means something else. We don’t want people to panic because they might find blood in the urine. Actually, a more common explanation is infection and so somebody with blood in the urine going to see his or her doctor would probably have a work-up for infection first and if it didn’t appear that there was any infection in the bladder then there would be a work-up to see if there’s another cause that might include bladder cancer. But blood in the urine is the usual first sign. It can look like a lot to somebody, even a trace amount of blood can be noticeable in the urine.
Benson: Most of the time, bladder cancer is detected early enough that it hasn’t invaded beyond the inner layers into the muscular outer wall.
McConkey: Probably 70-80% of the cancers fit into this category and those cancers are not usually lethal. Instead, they oftentimes can be managed by an out-patient surgical procedure, transurethral resection is what it’s called. The patient can go home the same day and then the only concern is these cancers often come back and so patients with these non-muscle invasive bladder cancers need to see their doctors regularly, essentially forever.
Benson: McConkey says survivability of lower grade cancers such as these can be more than 90%. However, they’re very expensive to manage. Patients may live for decades, every so often requiring another costly procedure.
McConkey: The higher grade cancers are still very survivable but they’re managed a little more aggressively. Usually when they become high-grade, the patients are managed first with a therapy called BCG which is instilled into the bladder and is very effective. It causes the tumors to go away in about 70-80% of cases. Again, the problem though is that after these high-grade cancers first respond to this drug BCG, they come back and the goal here is to help patients keep their bladders. And the concern is that surgeons don’t want to wait so long that the tumor spreads to distant places in the body and then becomes incurable. So, they know these cancers are potentially high-risk but they also know that they can be usually managed with aggressive therapy and the goal is to balance the benefit of helping the patient keep his or her bladder against the risk associated with leaving what could be a potentially lethal disease in the bladder.
Benson: As you’d expect, cancers that have invaded the muscular wall can be much more serious.
McConkey: While some of them, about half of them, can be managed either with surgery alone or with surgery plus chemotherapy, the other half can be very aggressive and can progress very rapidly and these cancers are thought to be almost as aggressive when they fit into this category as some of the more famous aggressive cancers like pancreatic cancer and metastatic melanoma, etc. So, muscle-invasive cancer’s not something to mess with.
Benson: Doctors and patients need to carefully weigh their options in these cases. McConkey says there are really just two choices.
McConkey: One would be to take out the bladder. And the case of that with chemotherapy added on, the survival rates are probably around 60-70%. The other approach would be to use radiation therapy, much is being used in prostate cancer, usually with some form of chemotherapy. They call that combination chemo-radiation. And in Europe, this is used more frequently than it is in North America and in fact, is in many sites preferred to taking out the bladder. And of course the advantage is that the patient can keep his or her bladder.
Benson: McConkey says a lot of work still needs to be done to investigate survival rates of aggressive radiation and chemotherapy versus bladder removal, but he says he believes we can reduce the number of people who lose their bladder and still survive. And that would be a major step forward in preserving people’s quality of life.
You can find out much more about bladder cancer and its treatment from the bladder cancer advocacy network at bcan.org, or through links on our website, radiohealthjournal.net. You’ll find archives of our shows there as well as on iTunes and Stitcher.
Our production director is Sean Waldron. I’m Nancy Benson.