Ask the Doctor

Spring 2006

This quarter we thank Dr. Seth Lerner, Associate Professor of Urology, Beth and David Swaim Chair in Urological Oncology and Scott Department of Urology, Baylor College of Medicine in Houston, Texas, for providing answers to the questions we posed to him.

Q. Can bladder cancer survivors ever count themselves in the “cured” column?

A. As with most cancers, the longer one goes without a recurrence the better. The majority of patients with bladder cancer are initially diagnosed with a non-muscle invasive cancer that can be managed initially with tumor resection via cystoscopy with or without intravesical therapy. These patients however, are at high risk for developing another tumor. The majority of recurrences occur within the first two years. The status of the bladder at the first three-month follow-up cystoscopy is a very important contributing factor to remaining disease free. Recurrent tumors do occur after the critical two year period, though less frequently, and patients should continue to be followed at least annually.

For patients with invasive cancer that requires bladder removal or radiation therapy with or without systemic chemotherapy, the majority of recurrences occur within the first two to three years after treatment. This timeline may be pushed back in patients who received chemotherapy. Five years is a good benchmark for determining outcome and the majority of patients who survive five years without a recurrence are likely cured. While much less frequent, recurrences do occur past five years in patients who have remained disease free, and annual follow-up is important for this reason.

Q. What are typical side effects of BCG? How do you know when your side effects are abnormal?

A. Side effects are very common and occur in up to 85% of patients. The most common are frequent urination, painful urination and a feeling of having to get to the bathroom quickly (urgency). Blood in the urine (hematuria) is common but usually self-limited.

When symptoms interfere with a patient’s ability to receive treatment on schedule, a dose reduction strategy can be used which will allow most patients to continue with BCG treatment. Anticholineric agents may also help patients with urgency and frequency.

When symptoms last more than 48 hours, treatment with the anti-tuberculosis drug isoniazid may be considered. More severe side effects occur in 3% of patients or less and include fever, joint pain and swelling, severe hematuria and in men, prostatitis or epididymitis. Treatment may be continued using a dose reduction strategy and with consideration of pre-treatment with isoniazid.

Systemic infection with BCG or other bacteria while rare, can be life threatening and requires treatment with broad spectrum antibiotics and isoniazid and rifampin.

Q. Doctors in Boston recently announced that they had successfully used cells from a patient suffering from bladder disease to grow a new bladder in a petri dish and then implanted that bladder into the patient. What implications does this development have for bladder cancer patients who need to have their bladders removed?

A. Tissue engineering offers the hope of “off the shelf” biomaterials that can be fashioned into replacement parts, many times using the patients’ own cells to constitute a functional organ. In the report from Boston, the doctors have taken a major step forward in bladder replacement for noncancer conditions. The patients who were treated had a congenital or acquired malfunction that resulted in a very small capacity bladder. Therefore, the described procedure was ‘bladder augmentation’ where a patch is added to increase the volume of the bladder. In achieving this remarkable feat, they used the patient’s own bladder cells to line the matrix that was then implanted on top of the existing bladder.

Since the bladder cells of a bladder cancer patient have a propensity to form tumors, an alternative source of cells is mandatory. Therefore, this model is not suitable for cancer patients. Adult (non-embryonic) stem cells can be obtained from peripheral blood, bone marrow, fat and from several other organs, virtually at any age. They offer the hope of a natural source of pre-cursor cells that can differentiate in an organ specific fashion. Although the researchers from Boston performed a bladder augmentation and not a complete bladder replacement, the initial results are an important milestone on the way to complete bladder replacement. However, since replacing a whole bladder is more complex than the described procedure, it will probably take several more years to achieve complete bladder replacement. The field of tissue engineering is growing rapidly and there are a myriad of potential applications for reconstruction in the genitourinary tract.