Ask the Doctor

Fall 2006

Mark Soloway, MD, FACS, Professor and Chair, Department of Urology, Miller School of Medicine, University of Miami, was kind enough to answer our questions for this issue of Outlook.

Q. There has been some discussion about substituting the term “superficial bladder cancer” with other terms. Why is that and what are some of the alternate suggestions?

A. The primary problem with the term “superficial” bladder cancer is that it has little real meaning. Superficial is defined by the dictionary as lying on, not penetrating. As currently used, superficial includes very low grade tumors which are confined to the surface or inner lining of the bladder (referred to as Ta) as well as high grade tumors which invade into the first layer called the lamina propria (labeled as T1). T1 tumors have the potential to spread and many times are deeper into the wall than we initially think. Thus the low grade Ta (confined to the surface) tumors have a different biologic implication than those that invade. These two types of tumors are two different animals and should not be grouped into a single category. Thus, we should eliminate the term “superficial” from our urology lexicon when it is used to describe a bladder tumor. Effective treatment begins with proper staging and an accurate dialogue with the patient and our colleagues. I believe that, to be on the same page, we must be accurate with our definitions.

Q. What can you tell us about the NMP22 test as a screening device? Do you recommend it? Can it be used alone or is it best used in conjunction with other screening tests?

A. The bladder tumor markers such as the NMP22 have roughly the same accuracy as PSA for the early detection of prostate cancer. PSA detection has dramatically altered the stage at which prostate cancer is currently diagnosed compared to 20 years ago before we had this indicator. Similarly if all of those with a cigarette smoking history or exposure to another carcinogen were monitored on a regular basis with a marker for the presence of a bladder cancer we might have the opportunity to detect life threatening bladder cancers at an earlier stage.

NMP22, like other products present in the urine in higher quantities in those with a bladder tumor than in those without a tumor, provides the opportunity to help with early detection. NMP22 is not the only such marker. Others such as Immunocyt add the benefit of looking at the cells for abnormal microscopic characteristics. The BTA test is another FDA approved urine based marker that is approved for the detection of bladder cancer.

Whether these tests should be used for patients with an established diagnosis of bladder cancer in an effort to diminish the use of cystoscopy is unclear and urologists are considering the tradeoffs involved in such a decision. These markers, like PSA, are not perfect. An individual may have a bladder tumor and the marker may not detect any abnormality or the test may read negative.

Q. In some cancers, the longer a patient goes without a recurrence indicates that there will be no recurrence of his or her disease. Is the same true of bladder cancer, or is a recurrence inevitable?

A. The carcinogen that often if not always causes bladder tumors may have caused an irreversible change in the bladder and thus will rear its head and induce a malignant change at any time. Thus, once an individual has a bladder tumor they are subject to a subsequent tumor which may be a true recurrence of the initial tumor or more likely a new tumor not related to the first, quite similar to skin cancers caused by exposure to the sun years before. Thus, there is the need for life long monitoring although the frequency of monitoring can be lessened as a longer interval between tumors is evident.