1  - Mike Riordan, Charlie Rinehart MD, and Paul Roach MD embark on a full discussion of Bladder Cancer: what it is, how it happens, how it behaves, and how it's treated.

2  - Guest: Charlie Rinehart, MD, a practicing Urologist and medical officer in the U.S. Navy, (formerly an officer in the USMC), undergraduate at Georgetown, Medical School at Columbia, and Urologic Residency at US Naval Medical Center, San Diego. Currently practices at the Captain James A. Lovell Federal Health Care Center, in North Chicago, Illinois

3  - Timestamps:

[00:24] - Intro & Charlie Rinehart, MD

A. Disclosure

B. Dr. Rinehart background & training.

[06:22] Overview of Bladder Cancer:

A. Incidence and Epidemiology

B. Clinical Presentation

C. Urinary system

[14:10] Hematuria and how is bladder cancer causing me problems?

A. Hematuria & its workup

B. Male / Female incidence & etiology.

i. Smoking Factors

ii. Occupational factors

iii. Low, Medium, High Risk

[21:06] Initial Workup of Bladder Cancer

A. Cystoscopy & Biopsy

B. CT Scan

[26:45] Tumor Grades and Depth of Invasion

A. Tumor Grades

B. Tumor Depth: Muscle Invasive and Non-Muscle Invasive

[36:00] Treatment & Surveillance of Non-Muscle Invasive Disease

A. Treatment

B. Surveillance

C. Why not bladder screening for everyone?

[40:50] Local Invasion & Metastasis

A. Pelvic organs

B. Lymph Nodes

C. Metastatic Behavior

D. Bladder removal (Cystectomy) and reconstruction

[50:00] Preventing progression from Non- to Muscle-invasive disease

A. BCG

B. Chemotherapies and Radiotherapy

[54:00] Bladder Cancer Endemic to East Africa & Middle East

A. Squamous Cell Cancer: Chronic Inflammation

i. Chronic Indwelling Urinary Catheter

ii. Parasite: Shistosoma

[57:45] Transitional Cell, Squamous Cell, AdenoCarcinoma Cell types

[59:30] Prevention

[1:01:30] Advanced Disease and Clinical Trials

[1:05:00] Closing

4  - Key takeaways in bulleted format:

-- Bladder Cancer happens to Men and Women, typically beginning in the more advanced ages.

-- Blood in the urine (either visible to naked eye, or only under the microscope) is a common feature.

-- Smoking (and some industrial exposures) important factors in its development

    -- "Transitional Cell" the most common type in USA and Europe; Squamous Cell (caused by a parasite called Shistosoma) also common in East Africa and Middle East

    -- Non-Muscle Invasive and Muscle Invasive frequently treated quite differently

    -- Chemotherapy, Radiotherapy, Immunotherapies available for Advanced Disease

    --  Important to not smoke, or quit smoking, to lower risk of disease.

-- In East Africa and Middle East, a type of bladder cancer can occur because of a parasitic infection.

5  - Relevant links mentioned in the episode:

https://www.cancer.gov/about-cancer/treatment/clinical-trials/disease/bladder-cancer/treatment

https://www.cancerresearchuk.org/about-cancer/bladder-cancer

https://www.cdc.gov/cancer/bladder/index.htm

https://www.cancer.gov/types/bladder/patient/bladder-treatment-pdq

6  - Follow us on your favorite Podcast program, and learn more through the homepage at https://paulbryanroach.com/so-its-cancer/

https://www.cancer.gov/types/bladder

7  - Coming up next month: "What Is Cancer?"

8 - Follow us on your favorite podcast platform, and link to show website is here: https://paulbryanroach.com/so-its-cancer/

paul_roach:

All right, everybody, welcome to SoDoc. It's Cancer, a podcast to understand cancer, how it happens, how it's treated, how we arrive at a diagnosis and at a prognosis, cancer's impact upon a person's quality of life, and how to move forward in life after a cancer diagnosis. The show airs monthly, and we welcome your engagement and feedback. Today... We have Michael Reardon,

michael:

Hi.

paul_roach:

and we also are excited and proud to present Charlie Reinhardt, MD, a urologist who is gonna talk to us about bladder cancer. Welcome to the

michael:

Welcome,

paul_roach:

show,

michael:

Charlie.

paul_roach:

Charlie.

charlie:

Alright, thanks guys.

paul_roach:

All right, Charlie, hey, do us a favor and just tell us a little bit about yourself, where you grew up, where you went to school, how you got interested in medicine.

charlie:

paul_roach:

Outstanding, outstanding. Now your wife was pretty thrilled when you decided to go to med school, is that right?

charlie:

She was excited. I'm not sure there's you know, there's positive and negative excitement I'm

paul_roach:

Well,

charlie:

not sure on the

paul_roach:

didn't

charlie:

spectrum

paul_roach:

she have

charlie:

of excitement

paul_roach:

some,

charlie:

where she was but

paul_roach:

yeah, she had some other ideas for you, but you're like, nope, hon, it's gotta be this.

charlie:

Yeah, yeah, her. She and there are some tears involved in and I think some screaming and pleading of why, why can't you just go to law or business school?

paul_roach:

Why couldn't you go? I mean, those are more sensible.

michael:

Hehehehe

charlie:

I don't do things sensibly. Yeah. She

paul_roach:

Yeah,

charlie:

knows that

paul_roach:

yeah,

charlie:

I like

paul_roach:

clearly.

charlie:

to take the hard route.

paul_roach:

Good, now one other person here actually enlisted in the Marine Corps. I'm not gonna

michael:

many

paul_roach:

say any

michael:

many

paul_roach:

names.

michael:

years ago yes

paul_roach:

Yeah,

michael:

in the marine

paul_roach:

how was

michael:

corps

paul_roach:

that?

michael:

reserve just just to be clear it was the marine corps reserve back

paul_roach:

All

michael:

in the

paul_roach:

right, well,

michael:

mid

paul_roach:

you were

michael:

to

paul_roach:

in.

michael:

mid to late 80s

paul_roach:

You had the haircut, you went through boot camp,

michael:

I did.

paul_roach:

where you excelled, no doubt.

michael:

No doubt.

paul_roach:

Yeah.

michael:

I never asked. So who knows.

paul_roach:

Charlie, when

michael:

But

paul_roach:

you were

michael:

yeah,

paul_roach:

a

charlie:

I...

paul_roach:

G...

michael:

semper fi, Charlie.

paul_roach:

Yeah.

charlie:

Yeah.

paul_roach:

When you were a GMO with the Marines, where'd you go?

charlie:

So I, and I should say when I was with the Marine Corps, I did, I did three deployments, but two of them were on ship, which is kind of what drove me to, to leave

paul_roach:

Yeah, yeah.

charlie:

and pursue other things. So, and when I got out, I said, despite going to the Navy, I said, I was not going to get back on ship. But when they sent me with the Marines. Six months of being with them. I was back on the ship for another eight months. So,

michael:

Good plan. Good plan.

charlie:

yeah.

paul_roach:

I know with the Marines you end up being out to see more than the sailors, you know?

charlie:

Yeah.

paul_roach:

Yeah. Ah, right. Well, all right. Well, I could see why you would depart that to go be a urologist and study bladder cancer. Now, what brought you into urology specifically? You're in med school, you've got every option, you could pick something sensible. You're like, no, I want to be a surgical subspecialist. What went wrong in that math?

charlie:

I mean, I tell everybody that it was a childhood dream of mine to be a urologist. You know, it's something about when you're drawing pics on your, you know,

paul_roach:

Yeah.

charlie:

in middle school when we have to be kind of messing around and drawing pictures on your buddy's notebook.

paul_roach:

Yeah.

charlie:

It was a budding sign that someday I'd be a urologist.

paul_roach:

This dude is gonna be a urologist someday.

charlie:

Now, it's a great specialty. There's a great mix of... both

paul_roach:

Ahem.

charlie:

patient, patients from young to old. There's a lot of different things procedural wise, we do a vast diverse types of procedures from open, big open procedures where we're taking out kidneys to a lot of minimally invasive endoscopic stuff where we're up with cameras taking out kidneys down. So, I just enjoy the breadth of it.

michael:

Paul, you lost your mic again.

charlie:

Take a minute, Paul.

paul_roach:

michael:

I know absolutely nothing about bladder cancer. So let's learn a lot. But from what you just said though, it sounds like at least in the U S that's a, a one in five, uh, fatality rate. That right.

paul_roach:

Yeah, I think so. And I think it takes its time doing it too. It's, you know, lung cancer and pancreatic cancer tend to move very rapidly. Bladder cancer, correct me if I'm wrong, Charlie, that is a slower time course.

charlie:

Yeah, it's, I, you know, with bladder cancer, I guess you can kind of a lot, a lot of different cancers. Um, it really depends on the stage of the cancer and kind of depends on, you know, both the stage and how aggressive the cancer cells are. So yeah, sometimes it can, sometimes it can actually just be low grade and recurrent and, you know, something that doesn't actually end up progressing this to that, to late stage, or sometimes it can be. something that's high grade and quickly progresses to that end stage.

michael:

Are there any indicators for whether it's going to be aggressive or a little more slow acting? Is that something that you can kind of predict or is it just sort of the luck of the draw?

charlie:

So there's definitely, there's grading scales. So I guess if we back up and kind of talk about how does someone end up getting diagnosed with bladder cancer, that probably will lead us into how

paul_roach:

Yeah,

charlie:

we determine

paul_roach:

yeah,

charlie:

what that

paul_roach:

I like

charlie:

grade

paul_roach:

it.

charlie:

is. But yeah, so the vast majority of bladder cancers are diagnosed after someone presents with blood in their urine. that's using the most common reason for pursuing a workup that ends up leading to a diagnosis of bladder cancer. So blood in the urine, and that blood in the urine can be visible blood that the patient can see, and we call that gross hematuria, or it can be microscopic hematuria, where they actually don't see blood, but they get a urine test, you know, usually for some other reason. They identify some red blood cells in the urine and it prompts them to be sent to a urologist for work.

michael:

All

paul_roach:

Do

michael:

right,

paul_roach:

they

michael:

so

paul_roach:

have,

michael:

that.

paul_roach:

oh, go ahead, Mike.

michael:

Well, I was just going to say that one of the things that we've been bumping into every time we do one of these podcasts is how important it is to go and have that annual physical. Um, because basically what you're saying is, yeah, if I see blood in my urine, I I'll go to the doctor right away, but I only go to the doctor once a year, but they can see if I have blood in my urine, even when I can't, if they're running, um, that they're, they're, if they're doing the labs on, on a urine sample that I have to give, right.

charlie:

Correct. If you do have blood in the urine, they likely will pick that up on a urine test. Now, again, there's some controversy and it's, you know, I don't, as far as what the standard practice for lab tests, annual lab tests, in urinalysis is not necessarily one that's always done every year you go to the doctor. There's various reasons you get a urinalysis. But, you know, as far as your annual screening, it's not always one that you're going to... they're gonna get.

michael:

Something we should push for maybe.

charlie:

Well, you can make that argument that you could and I would probably say, you know, from my standpoint, probably if you're high risk for bladder cancer, for the most most people that are not in any high risk, you know, the problem with doing too many too many urinalysis is you're going to pick up red blood cells for many other things and it's going to lead to a lot of unnecessary kind of trips to the To be clear, just because you have blood in your urine does not mean you have bladder cancer. There's many different reasons that someone might have blood in the urine, both gross hematuria, so visible blood, or microscopic hematuria. Bladder cancer is probably fourth or fifth on the list, but because it typically has the most consequential, that's what prompts that workout.

paul_roach:

Well, and you know, to take a step back, just to kind of describe the urinary system. So, you know, you have somewhere between four and a half and a five and a half liters of blood in your, in your, in your veins and your heart's pumping 60

michael:

Can we talk about

paul_roach:

to.

michael:

pints, Paul? Can we talk about pints, please?

paul_roach:

I don't know how many pints that is. Yeah. But

michael:

Isn't

paul_roach:

anyway,

michael:

it like

paul_roach:

you're.

michael:

10?

paul_roach:

15, 15 pints we'll say. And your heart's pumping away, knocking that stuff through your whole system. About 25% of your heart's output will go to your two kidneys. So your kidneys are these filters and they're filtering out impurities in your blood. Now almost all of that blood the kidneys give right back to the system, but. there's this little filtrate that comes out in the form of urine. You got a kidney on your left side and a kidney on your right side, typically, and they have a little tube. The kidneys are high up in your back. If you think about where a kidney punch is, it's back up there. And then that little tube drains it down to your bladder, which is down low, right behind your pubic bone, where it collects and hangs out until it is a socially... appropriate time for you to relieve your bladder, and then boom, there you go. So what we're talking about is a cancer of that bladder, and it's a growth, a malignant growth, typically starts within the lining, the inner lining of that bag. So that's just sort of framing the overall whole thing. How'd I do?

charlie:

That was great. That was great.

paul_roach:

Mike,

charlie:

I don't

paul_roach:

bye.

charlie:

know about your pint, your pint measurement, but the rest of it was probably pretty

paul_roach:

Yeah,

charlie:

accurate.

paul_roach:

I just kind of threw that one out there. Figured. Yeah.

michael:

I'm worried, Paul. What medical school did you go to again?

paul_roach:

I actually didn't, yeah. I

michael:

Excellent.

paul_roach:

just said I did. This whole thing has been.

michael:

So Dr. Charlie,

paul_roach:

Yeah, stick with Charlie. He

michael:

but

paul_roach:

went to.

michael:

as long as we're talking about bladder cancer, now the way Paul set that up, it sounds like it's actually just a simple bladder is just a very simple little container. So how is this causing me potentially life threatening problem?

charlie:

Yeah, so it's, unfortunately it's, it's not that it's not the local issue with the bladder. It's, it's when they, it's, it's when the cancer spreads beyond the bladder that causes, it causes the majority of kind of the fatal issues for sure. Um, but yeah, so I can take as far as kind of stepping back to, to the diagnosis, we talk about blood in the urine and there's a number of reasons you got blood in the urine. So whether it's. There's kidney stones, infection for most, for men after, you know, certainly as they get older, the prostate gets larger and as the prostate grows, it could be prone to bleeding. And that that's a probably the most frequent cause of blood in the urine for older men. Um, the kidneys as, as, as Dr. Paul was alluding to the kidneys, filter out the blood if there's some problem with. the kind of the way the kidneys are functioning, filtering that can shed red blood cells into the urine. And so you can get blood in the urine kind of that way. And so, yeah, so when someone, when someone either has blood in the urine or sees blood in the urine, or it's picked up on a urinalysis, they're referred to a urologist. And so the workout, we call it a hematuria workout. So the workout for blood in the urine. That's what hematuria means, consists of really two different things. So the first thing is some type of imaging. And it's usually imaging of what we call the upper tract. So as Paul was describing that urinary tract, the kidneys, he had mentioned these things called tubes. These tubes are called ureters. So the kidneys make urine, the urine collects in the collecting system of the kidney, and then it comes down to the ureters. into the bladder, plugs into the bladder where it's stored until we're ready to urinate. So we have to get some type of imaging because to be, we call it bladder, it is bladder cancer, but bladder cancer is cancer of the cells that line the bladder. Those same cells line the urine and they line the collecting system of the kidney. And any tumor of any one of those areas can cause blood and urine. So we'll get imaging. Usually that's in the form of a CT scan. It could be in the form of an ultrasound. And then we'll take, do what's called a cystoscopy. Every men's worst nightmare when they come to the urologist, but really not that bad. We'll do a camera up into the bladder and take a look around. Cause the imaging will show us kind of things in the upper tracks, but it's really not, not 100% diagnostic for what's going on in the bladder. So we have to take a look at. the bladder with our own eyes.

michael:

You just said something interesting that this is every man's worst nightmare. Um, but at the same time, women have kidneys and bladders and ureters. Uh, is this, is this predominantly a male, uh, illness or is it, is it equally distributed?

charlie:

No, it's so I think we do see a little more water cancer in men than in women, but that was to note that the point of camera most men are a little bit worried about getting the camera into the urethra if you can imagine that. Maybe you don't have to, but women typically tolerate it a little better than men do.

michael:

Ah, okay. But yeah, I was just curious if that would be like kind of a gender bias for the disease, but it's not.

charlie:

No, I would say it's probably a little more prevalent than men, but it's, but you know, everybody gets the workout, but you know, men are, men are a little, we do see a little bit of men and men are, they're kind of criteria, they're a little bit higher risk than women.

michael:

Could that be because there's a tendency of men also to not, for lack of a better way of saying it, less frequently visiting the doctor, less taking care of themselves medically than women tend to do. Like

charlie:

It could, I

michael:

women

charlie:

think it's

michael:

will

charlie:

probably

michael:

catch

charlie:

also

michael:

you.

charlie:

related to smoking habits. Smoking is, is the number one, uh, kind of linked cause to bladder cancer. You know, probably the prevalence men smoke more than women. I think it's probably just, I think we

michael:

Okay.

charlie:

see that in lung cancer too. Outcomes are not different, but, but then, you know, I think we see a more lung cancer of men because of that reason. If all, what do you think? Is that.

paul_roach:

Yeah, I think that's probably 100% of the difference or somewhere close. The strongest risk factor, so environmental exposures are supposedly most of the cases of bladder cancer. And of that, the chemicals are cigarette chemicals. There's at least 60 known carcinogens. in the cigarette smoke and it gets into your bloodstream, obviously that's why you smoke it. It answers your lungs, your lungs are incredibly well perfused. The chemicals get into the blood right away. They get filtered through the kidneys and then they wait to get out in your bladder. So they're just hanging around in the bladder until you pee with a lot of contact time against the lining. So that explains that. Other kind of chemical carcinogens are occupational. And there's a variety, maybe metal workers, painters, rubber industry, leather, textile, electrical, miners, cement, you know, a variety of things, industrial chemicals, where somehow those chemicals get into your bloodstream as well, and then they're hanging out and... it waiting in the bladder until you pee. So a lot more contact time with it. But of the two, I think smoking is much more of a problem than exposures to other chemicals, just from what background reading I had done.

charlie:

Yeah, I would agree. I'd agree. In fact, it's, you know, it's part of the, when we, when we see somebody that comes in for a humanitarian, for a workout, we will risk stratify them into kind of low risk, moderate risk, high risk. And some of that's based on age of the patient. Some of that's based on how much blood was seen in the urine. But a history of smoking puts them, you know, kind of elevates their risk. Um, for sure. If they have a history of smoking. we're going to be more, more apt to be, you know, kind of, to be more aggressive with the, the workout.

paul_roach:

So let's say someone comes in and let's just make them moderate to high risk. They smoke a pack a day for 30 years or 40 years. They're

charlie:

High

paul_roach:

60,

charlie:

risk, automatically

paul_roach:

all right,

charlie:

I'm ready.

paul_roach:

all

charlie:

So

paul_roach:

right,

charlie:

you

paul_roach:

65

charlie:

put them in the high risk

paul_roach:

years

charlie:

category.

paul_roach:

old. All right, and the first thing you're gonna do, their primary care physician, sent them to you because they had blood in the urine or maybe some voiding symptoms. And then you're gonna do a cystoscopy and a CT scan.

charlie:

Correct. Yeah.

michael:

What's a cystoscopy?

charlie:

So Sistosky is that dreaded thing that I had alluded to earlier. So that's

michael:

Uh.

charlie:

fancy term for small camera, end of the block.

paul_roach:

Through

michael:

Okay. Guy got

paul_roach:

the

michael:

to keep

paul_roach:

urethra.

michael:

Paul honest. He's always trying to,

paul_roach:

Yeah.

michael:

you know, we went

paul_roach:

Yeah.

michael:

to high school together. He's always trying to beat down the fact that I beat him on an honor roll every semester.

paul_roach:

Every semester, every semester. Yeah.

michael:

See?

paul_roach:

Yeah.

charlie:

Yeah. Well, if I tell patients we're going to do a cystoscopy and that'll get them to come back at least. If I tell

michael:

Oh.

charlie:

them we're going to take a small camera

paul_roach:

putting

michael:

Gotcha.

paul_roach:

it in your penis.

charlie:

and stick it up the tube you pee out of, they

paul_roach:

Yeah,

charlie:

might not come back.

paul_roach:

yeah.

michael:

Fair enough. Cystoscopy it is.

paul_roach:

So, you put the little camera through the urethra into the bladder and you're looking around at the bladder and you see this friable mass on the wall and you're like, that's probably gonna be a tumor. So how do you deal with it then? What happens at that point?

michael:

Alright, I have to stop you again, Paul.

paul_roach:

Yeah.

michael:

Friable mass.

paul_roach:

Ah, my apologies. So the inner lining of the bladder is gonna be nice and smooth and perfect. But if, on that lining is this lump and it's looking like it, you know, you tap it and it starts to bleed or, you know, it looks very fragile and it's this kind of mass that's... ruining the otherwise perfect lining of your bladder, that's what I'm thinking of as a friable mass.

michael:

Okay, because Fryable threw me. You know

paul_roach:

Sorry,

michael:

what that...

paul_roach:

sorry, yeah, that's a term we use a lot. We throw that around. It just means it's really delicate and if you touch it, it will bleed.

michael:

Okay. They're not like my Sunday breakfast. Friable.

paul_roach:

I'm going to go ahead and turn it off.

charlie:

Nothing to eat. Yeah, so if someone has any type, if they have a bladder mass or just some irregular tissue, we're not really sure if it is, you know, really the next thing to do is we've got a biopsy somehow, right? That's usually the next step for any, anytime you find something abnormal in the body is let's figure out what it is. Now, I mean, most of the time looking at it, I can tell, you know, it's a bladder cancer and the vast majority of bladder cancers are of a certain type, these urothelial cell which line the bladder. But we got a biopsy. And so we'll set them up. We have to do it under anesthesia, but we'll set them up for what's called a transurethral resection of bladder tumor, a turbit as we kind of call it. But that's where we're going to go in. essentially shave that mass down from within the inside the bladder so we can both kind of get a diagnosis of what it is and also will help us stage kind of the depth of invasion.

paul_roach:

Now that's pretty slick. It's not like they have to make an incision through your abdomen and go down to the bladder and open up the bladder and then go after it. They just threw the tube you pee out of, they put in these slender little cameras with instruments and they're able to shave it off that way. They don't have to open you up at all. So, that's the way it works. Now, I'm gonna show you how to do it. So, you're gonna have to go to the

charlie:

Correct, yeah, we try to not open up anyone for things that we wouldn't have to. So yes, it's a cystoscope. It's a little bit bigger than the one that we use in clinics. That's why we have to go to the OR for an effort in a number of reasons. But yeah, we'll go in the bladder. We'll shave it kind of down layer by layer. These things, as Paul said, they're friable, but they've kind of developed their own blood supply. And then so they're... bleed a lot so we kind of have to take a belay while we're able. We'll shave it down and then we'll try to get essentially down to what appears to be the base of the bladder wall. You know, kind of maybe not healthy tissue but down to the place of the bottom of the muscle and once we do that we, you know, that's all we do in that case and we send that, the tissue gets sent to pathology. And the pathologist will then, they'll do a couple of things. They'll look at kind of the grade. It will assert, first of all, they're going to look and say, Oh, is this, is this a malignant, is this cancer or is it something else? Um, most of the time, like if we're in doing this, uh, it's, it's probably cancer. And, um, they'll tell us whether it's, they'll grade it out in terms of high grade, low grade, and then. There's a couple other kind of grading type terms they'll use, but essentially high grade, low grade, and then the depth of the invasion. So

michael:

Charlie,

charlie:

does

michael:

what

charlie:

it...

michael:

does that mean if it's high grade or low grade?

charlie:

So that's kind of a term that pathologists use, and it kind of tells us a little bit about how likely that cancer, I think, is to spread in terms of how aggressive the cells are. Cancers can be irregular, how irregular and how prone to kind of uncontrolled growth. What would you say, Paul? It's similar in other. oncologic fashions, how we describe it.

paul_roach:

Oh yeah, yeah, yeah, yeah. So we're actually, I think next month gonna be talking about what is cancer just as a general subject, and we'll get into a deeper dive on it then. But in general, you have your normal cells, and when you look at them with a microscope or any other modality, they have a nice regular pattern to them. It's like you're looking at anything with a normal. a regular pattern, if you're looking at flagstones or bricks in a wall or a fabric with a repeating pattern on it and everything looks the same and it looks nice and regular, then the more and more and more deviated from that regularity that it looks, the higher the grade the tumor is. So if it's a low grade tumor, it looks pretty normal. There's some changes. You know, we have details that we discuss, such as the nuclei and their shape and their arrangement. But for the most part, they don't look too far removed from what you typically see. But if it's completely chaotic and totally out of bounds, then that's a higher grade tumor. And you have concerns that the inner expression of each of those cells is more distorted from normal, and that typically correlates with increased aggressiveness. Does that make sense?

michael:

Sure.

paul_roach:

So

michael:

Thank you.

paul_roach:

a low-grade tumor is pretty close to normal, and a high-grade tumor is far, or farther away, and we worry more about the high-grade tumor's propensity to invade locally and to invade and to go away distantly.

michael:

Okay, yeah, that definitely does make sense.

paul_roach:

All right, sweet. So you get in there, Charlie, you see this thing with your eyeballs, you're like, hey, that doesn't look good. I'm gonna shave it down. You shave it down to what's pretty normal. You send that to the pathologist. They look at it and they say, that doesn't look good. And whether it's low grade or high grade, what do you do next?

charlie:

So, as I was kinda mentioning, they're looking at the two things, they grade them and they look at the depth of invasion. And bladder cancer is primarily kinda grouped into two categories. One category is called muscle invasive, where it invades the muscle of the bladder. Bladder is ultimately a muscle. It's called the trusor muscle. So whether it invades the muscle... or whether it's non-muscle invasive, meaning that tumor has not invaded the muscle. And that really kind of will guide therapy. We have these two very distinct treatments for non-muscle invasive bladder cancer versus muscle invasive bladder cancer. So that's kind of the one, the first thing we're, as a urologist, we're looking from the pathologist to tell us is whether or not that tumor invades the muscle. Because if it does invade the muscle, it's going to send them down a completely different treatment pathway than if it's non-muscle invasive. And then if it's non-muscle invasive, and low-grade tumors do not invade the muscle, so if it's non-muscle invasive, bladder cancer, then we're looking at whether it's low-grade, high-grade, and that will determine how the treatment is dealt with in that sense.

michael:

So if it's limited to the lining of the bladder, that would generally be considered low grade. And as the tumor can get anchored in and continue on through the lining to the muscle wall, that's when it becomes kind of more dangerous and more higher grade.

charlie:

That's correct. So in some sense, so high grade muscle doesn't necessarily mean it's invaded the bladder wall. You can have non-muscle invasive high grade, but that has a more likelihood of becoming muscle invasive if it's high grade.

michael:

Hmm.

charlie:

So I guess you could look at it this way. If you find it early enough, it could be high grade, but it has not invaded the muscle wall, but it might head that way if we don't deal with it versus those that... have already invaded the muscle wall. And those are going to be high grade. But we've caught them by the time they've already invaded into the muscle.

michael:

Right. So I'm seeing a parallel here when we, we talked about, um, skin cancer where they were talking about, there's some that can sort of spread on the skin and there's some that kind of go deep into the skin. And the ones that they really worry about more are the ones that go deep into the skin. It sounds like it's almost the same thing. It's going deep through the lining into the, um, uh, muscle, a little faster. Uh, so that's generally where the, the aggressive nature kind of has you concerned. sort of the same process.

charlie:

Yeah, I would say it's a good comparison. Yeah, so low grade, so non-muscle invasive bladder cancer, if it's non-muscle invasive, the reason that's kind of different is that, actually, if it's muscle invasive bladder cancer, the treatment, if the person can sustain it, is to have the bladder removed. Okay, so that's a pretty, which is a pretty drastic measure. Non-muscle invasive bladder cancer, there are a number of treatment options, treatment steps that we will undertake that are bladder sparing. And so that again, that's kind of why we look for that, non-muscle invasive versus muscle invasive. Now, if it's non-muscle invasive, that is the majority of bladder tumors that we find are non-muscle invasive. And so if it's non-muscle invasive, then we will risk stratify these into low risk. intermediate risk and high risk based on some of the kind of the features of the cancer that the pathologist has shown us and on some of the kind of the history of the patient and how big the tumor was and how many tumors there were. So we will risk-fy it to low, intermediate and high risk. If that

paul_roach:

Now

michael:

So

charlie:

makes

paul_roach:

with,

charlie:

sense.

michael:

if I'm, go ahead, Paul.

paul_roach:

okay, with bladder tumors, is it you'll find just one or is it a field effect where if you find one, there might be others?

charlie:

So it's often we'll find one, but you can find one, you can find more, you know, and if it's, if you find multifocal, meaning that there's more than one, that's kind of the term we use for, you know, more than one tumor, multifocal, that puts it in a little bit higher risk category than if you find a single tumor.

michael:

What's more common? Is it more common just to find the one and

charlie:

It's

michael:

deal with

charlie:

more

michael:

that?

charlie:

common

michael:

Or...

charlie:

to find just the one, you see, but it's, we see patients that will come in with maybe one primary one and a couple of small tumors, kind of satellite tumors, recall, just over next to them. So, I'm gonna go ahead and show you what's going on in the patient's body. So, I'm gonna go ahead and show you what's going on in the patient's body. So, I'm gonna go ahead and show you what's going on in the patient's body.

michael:

So if I, I'm putting up my air quotes here, I'm lucky, and I just have the low grade and I'm still on the bladder lining, my tumor is there, what's the treatment for me? And what does that look like in terms of going in, recovering, is this kind of relatively quick and easy? Or is this something that I'm gonna be worrying about for months and months and years? How

charlie:

Yeah.

michael:

does it happen?

charlie:

Right. So let's go. Yeah. Let's start at the lowest. You know, what's the best, best case scenario scenario. So the best case scenario for someone is if they have, if you, you go in and you have a single lesion. As you, we respect that we send it to the pathologist and they say, okay, it's, it's a low grade tumor, non-muscle invasive. And so you have a, so you say have one, a single low grade non-muscle base of tumor. And so that would be, could put you in the lowest category. And so if we have resected that entire, you know, we, we think we had a good resection during that initial procedure, that might be the end of it from a, I guess from a cancer standpoint. Now there's surveillance that is required for all of these, but that might be, that might be your only treatment that you're going to.

michael:

All right, so basically the biopsy, you took a, and by resection, right, you mean you just cut everything out during the biopsy. Okay,

charlie:

Correct.

michael:

and so if that happens, I'm pretty much good, and you just sort of keep an eye on future urinalysis tests and things like that.

charlie:

So it's a little more involved in that. So, and probably one of the things that with bladder cancer, despite it being somewhat of a rare cancer in terms of the kind of list, I think Paul said the ninth most common. For urologists, it's probably the third, we see much more prostate cancer, we probably see more kidney cancer, but bladder cancer is a very kind of. intensive surveillance kind of regimented process. So, you know, I had seen somewhere that probably lifetime treatment of bladder cancer is the most expensive cancer for lifetime treatment of patients because

paul_roach:

Wow.

charlie:

it's not just you remove it, but then there's a long-term surveillance. So surveillance for low-grade, you know, it depends on the grade, but will involve repeat some urine, what's called cytology tests, where we send the urine to the lab, they spin it down, and then the pathologist will look into the microscope to see if there's any cancer cells. So a combination of those kind of things, and the higher the risk category you fall in, the more frequent you're doing these things.

michael:

So this sounds a little bit like, uh, like the colonoscopy that, you know, once I hit 50, I had to go in and have done, why am I not at 50 or 60 or 70 or whatever the age category is, they're not a predetermined sort of test that says, Hey, you're at that age. You're at that kind of risk just by age alone. Um, you should have a cystoscopy. if I said that right.

charlie:

I think it's just because bladder cancer is not as common. It's not as common.

michael:

Is that a good idea though or am I just, you know,

paul_roach:

Well,

michael:

being

paul_roach:

it's

michael:

silly?

paul_roach:

a good idea. And again, I think another deep dive we could do, we could do a whole episode on screening, but for screening exams, in order to make it, they have to be practical and reliable and valid. And in order for them to be practical, you need a prevalence within the population that's high enough to merit a screening test, because every test is gonna have some bad things that can happen because of the test.

michael:

Gotcha.

paul_roach:

And there could also be error. And so even something as simple as a chest x-ray screening for lung cancer, it can send you down the path of chasing down needless things and then we're gonna do a biopsy and now their lung collapsed and, oh, it was all for nothing anyway. That also happens all the time with mammography and breast cancer. If you're gonna catch a breast cancer early, you start doing mammograms when they're 40, but the vast majority of things that you find aren't breast cancer. So you're putting these young women through all this stress and money and sometimes even side effects of your treatment, and it's not even breast cancer. So

michael:

Okay.

paul_roach:

with the bladder cancer, it's so rare that

charlie:

Yeah.

paul_roach:

sticking a cystoscope up, everybody, that's a lot of trouble. It doesn't... You won't yield enough.

charlie:

Yeah.

michael:

Okay,

charlie:

And

michael:

so

charlie:

that's,

michael:

and the prevalence

charlie:

I mean, it's,

michael:

is far

charlie:

I think

michael:

less?

charlie:

that's, yeah, I think that's, you know, it's the cystoscopies, but it's also the, you know, kind of the, um, what happens next. Cause we will, some things look very much like bladder cancer. You get in and it's no doubt about a cancer. And then sometimes we do cystoscopies on, on men and women that there's just a little bit of irregularity to the tissue. And that kind of prompts us to take them to the operating room. They're going. to do a biopsy and it might just be inflammation. You know, they had an infection or something that caused the tissue to look a little bit irregular. And so we've kind of, we accept that we're going to do some, we're going to have some negative biopsies in the pursuit of finding the cancer. But if you start sending everybody some staphs, those negative biopsies are going to go way up. And so we'll, you know, exposure to anesthesia and trips to the operating room. that kind of stuff.

michael:

Okay.

paul_roach:

So cancers.

michael:

And it's just not as prevalent as colon cancer. So that's why you're not

charlie:

Yeah.

michael:

going

paul_roach:

Right,

michael:

to do it.

paul_roach:

right, right. So cancers do two major things. They invade locally and they metastasize distantly. So where your bladder's sitting, right down low in your pelvis, if it invades locally, Charlie, what does that look like?

charlie:

So local invasion typically, I mean, it can invade into the surrounding organs. So for men, it can invade into the prostate, it can invade into the pelvic sidewall. Then, you know, that's kind of the time, you know, for women, you can invade into the anterior vaginal wall, you know, different kind of just local. That's typically what we find with kind of local invasion.

paul_roach:

And then does it frequently go to the lymph nodes in the region or does it go to other organs when it metastasizes, where does it like to go?

charlie:

Typically, when it when it metastasizes, typically first it goes to the regional lymph nodes. So your pelvic lymph nodes are kind of where it will go to first. And that's so when we do when we do a surgery to remove the bladder for bladder cancer, we will also take out the pelvic lymph nodes along with them. That's both, you know, that's both for some treatment effect, but probably also diagnostic and prognostic effect. Cause we can, if it's spread to the left nose, we know it's already left the bladder and therefore it's going to treat it, probably send us down to some systemic treatment as well.

paul_roach:

But bladder cancer doesn't respond too well to chemotherapy, does it?

charlie:

Um, so

paul_roach:

I don't

charlie:

it's,

paul_roach:

know, but...

charlie:

yeah, it will respond somewhat. I mean, but it's not, you know, as opposed to some other cancers that we treat, lesionologist, you know, some of the testicular cancers respond just incredibly well to chemotherapy, um, where it's almost a curative effect. Uh, you know, we don't have that same success with treating bladder cancer with chemotherapy, um, but that is for metastatic, um, disease or sometimes we'll get chemotherapy in what's called the neoadjuvant setting or the adjuvant setting. So after surgery to kind of wipe out any microscopic spread that might be there. We do use chemotherapy.

paul_roach:

All right, and do you use radiotherapy too, x-rays?

charlie:

Radiotherapy has a limited role. Pretty much the only role for radiotherapy is, so say a guy comes, we kind of mention that. If you have muscle invasive bladder cancer, almost always the recommendation, if you are healthy enough for surgery, the recommendation will be to remove the bladder.

paul_roach:

Wow.

charlie:

Some individuals, some patients are not healthy enough for surgery or they don't want to go through that surgery, which is a major surgery, and so we'll do what's called kind of bladder sparing. And it's also known as tributal therapy. So the kind of three arms of that therapy is a full resection, endoscopic resection, like I've done before, like we've done to diagnose it, plus chemotherapy, plus radiotherapy. And that's the treatment option for muscle-invasive bladder cancer for individuals that do want to or are not candidates to have their bladder removed.

paul_roach:

So if they have to, let's say they have muscle invasive and they have to remove the bladder, you have to remove the bladder, what do you do with the urine? Because you're making

michael:

Yeah,

paul_roach:

it

michael:

I was

paul_roach:

every

michael:

just going

paul_roach:

minute.

michael:

to ask the same thing. I mean, are there internal prosthetic devices? Are these external prosthetic devices? I had an uncle who had some kind of bag that was attached to, he had to strap it onto his thigh or something like that. Is that what this was? Or is there a way to have an internal fake plastic bladder put in or something?

charlie:

Yeah. So, yeah, so we have to divert the urine somehow, right? So it was going into the bladder, and so we either have to divert it somehow out of the body through something else, or we have to kind of create what's called a neoblader. And so what your uncle said was probably just a catheter, but he might have just a catheter that was draining into your back. For... For bladder removal, the most common way to kind of get that urine out is to create what we call as an ileal conduit. So ileum is part of the bowel, it's part of the small bowel. Dr. Paul can tell you much more about the purpose of the ileum. For urologists, the purpose of the ileum is to serve as a kind of a source for bladder substitution. So we'll take those ureters, those tubes that we saw during... urine down from the kidneys and we'll remove, we'll take a section of ileum, we'll kind of separate it from where it is in the small bowel, replug the small bowel together so the bowel has continuity or continues and then we'll take that section that we we separated and we'll plug the urine through that and then we'll bring it out to the abdomen to a ostomy which then the urine will drain through that. just

michael:

Alright.

charlie:

into a bag that's then attached to the stomach, that's taped to the stomach.

michael:

On the outside.

charlie:

on the outside. Yeah. So that's an ilio content. Now we can, there's, there's other ways. So we can also take, um, we could create what we call a neo bladder. I mentioned, mentioned that. So a neo bladder is essentially where we are going to create a reservoir to collect the urine that is going to be anatomically where the bladder was. Um, and so we'll use, you can use, you can use different segments of the back, you can use small bowel. You can use parts of your large bowel. You can even use the stomach, parts of the stomach. There's different ways to create these different diversions. But a neo-bladder, we'll take, say we'll use a longer segment of small bowel and we'll create kind of a reservoir and we'll put it down in the pelvis where the bladder was. We'll connect it to the urethra. So you have some of the same kind of... steps of urinating where you're still urinating through your urethra, but you don't have the same urinary function because it's not a muscle like the bladder was. It doesn't function the same way as storage and emptying. But it's for patients that don't want to have a bag on their stomach, it's a good option.

michael:

Well,

paul_roach:

Is this?

michael:

when you say that it's not a muscle, so the bladder itself, you know, like I know when I when I have to go right, I feel that. But and I and I will for lack of a better time that a doctor it like

paul_roach:

Thank you.

michael:

I will that that muscle open. But if you're replacing that with a piece of stomach or small intestine, do I lose that? So

charlie:

Yeah,

michael:

it's

charlie:

you

michael:

really

charlie:

lose

michael:

just sort

charlie:

that.

michael:

of

charlie:

You don't, it's the same. So you have to kind of do what we call Valsalvoid, or you kind of wear abdominal voiding. Instead of having the muscle where it squeezes down to push urine out, you're having to kind of squeeze your stomach and relax to push urine out. So it's not nearly as effective as your natural form of urinating.

paul_roach:

As simple as that darn bladder is, turns out to be pretty important. It's nothing more than just a little muscle coated on both sides with the lining, the inner lining and the outer lining, but removing it and then trying to replace that function is an enormous problem.

charlie:

Yeah. Yeah, absolutely. I mean, it's, it's, it's, you know, from a urologic standpoint, it's a cystectomy. That's the name of the surgery. It's cystectomy is one of them without a doubt. You know, if not the most, one of the most major surgeries that a urologist will do and patients, um, you know, it's, it's not done lightly. Uh, those, those patients, it's, it's not an easy recovery. It's certainly a huge change in quality of life for them. And that kind of brings me back to this muscle invasive versus non-muscle invasive, because that's a really critical point in the whole diagnosis of bladder cancer is, is how do we find, you know, let's get these guys that are non-muscle invasive, and what do we do to treat them to hopefully prevent progression to muscle invasive? disease. I kind of didn't talk a lot about some of the treatment options for non-muscle invasive. We talked a little bit about if it's a low grade, you take it out, and maybe you're done with some surveillance. But there are some treatments that we use for intermediate and high risk non-muscle invasive bladder cancer. And interestingly enough, one of them, probably the mainstay of treatment for non-muscle invasive bladder cancer. is to inject medications into the bladder periodically. And the main medication we use is actually BCG. So yeah, I don't know if you've ever heard of BCG. If you lived in South

michael:

Never.

charlie:

America, you would probably know what BCG is because you would have had the BCG shot. So BCG is, it stands for bacillus, C is commie, gurnin. It's a French term, but it's the vaccine for tuberculosis. We don't

michael:

Really?

charlie:

get it in the US because we don't have nearly, really don't have much tuberculosis at all. But in other parts of the world where it's more prevalent that you get the vaccine. Well,

michael:

And

charlie:

go

michael:

that

charlie:

figure.

michael:

somehow.

charlie:

Someone figure it out. If you put BCG in the bladder, it somehow creates a reaction and treats bladder cancer.

michael:

That's

paul_roach:

How

michael:

crazy.

paul_roach:

do they make that leap? Yeah,

michael:

Yeah,

charlie:

Yeah,

michael:

what

paul_roach:

you

michael:

mad

paul_roach:

know,

michael:

scientist

paul_roach:

but.

michael:

put

charlie:

that's

michael:

that

charlie:

a good

michael:

one together?

charlie:

question. I don't know, you know, things that would be tough to get approved probably these days, but, but yeah, that's the mainstay for non-muscular sublastic. There's a couple other chemotherapies that are used, but those are usually reserved for cases where the patient's refractory means that BCG has not worked. It's, it's recurred in after getting BCG. But But most guys, if they, most guys, I say guys, but men and women who are diagnosed with intermediate or high risk bladder cancer will put them through a regimen of BCG treatment where they will get, they'll come in and get them. They'll get this BCG put in the bladder. They leave it in for two hours and then, and then urinate it out and they'll repeat that weekly for some periodicity. depending on where the risk category they fall in, it can be up to three years.

paul_roach:

Wow, so

michael:

Weekly.

paul_roach:

my

charlie:

Not

paul_roach:

understanding.

charlie:

weekly, not weekly for three years, but at given intervals up to three years.

paul_roach:

And so the BCG is a vaccine. Its job is to stimulate the immune system. When you inject it into the shoulder to prevent tuberculosis, you know, the point is to sort of educate the immune system so that when it encounters tuberculosis, it can attack it effectively. So when you put it into the bladder, is it the same basic mechanism of action where you're squirting it into the bladder and its job is to sort of ramp up the immune system? and so that it will attack anything that doesn't look quite right. And maybe it's going to attack that tumor.

charlie:

I, it's considered an immunotherapy. So yeah,

paul_roach:

Yeah.

charlie:

they don't exactly know how it works,

paul_roach:

Yeah.

charlie:

but yeah, that's the idea. It stimulates some kind of immune response.

michael:

It makes me wonder if there's some correlation between tuberculosis, uh, you

paul_roach:

And

michael:

know,

paul_roach:

bladder

michael:

what,

paul_roach:

cancer?

michael:

what, and the

paul_roach:

Yeah.

michael:

cancer that's, yeah,

paul_roach:

See?

michael:

otherwise

paul_roach:

You could

michael:

it makes

paul_roach:

have gone

michael:

no sense

paul_roach:

to med

michael:

to me. Could

paul_roach:

school, Mike. You would have. You got

michael:

have.

paul_roach:

the right idea.

michael:

Yeah. This is art school or, or med school. It was such a toss up.

paul_roach:

Um, so this is oddly enough, Charlie, we have an audience in Africa. And, uh, and so for our African audience, uh, can we spend a couple of minutes talking about the types of bladder cancer endemic to specifically like East Africa and the middle East.

charlie:

Yeah, we can. I'll caveat my experiences mostly with what we see here in the US was this predominantly urethralial cell. So there's other types of bladder cancer that we can see. So urethralial cell, again, that's the most common. That's cancer of the cells that line the bladder. most common that we see is squamous cell. And it's diagnosed just the same as any urethelial cell, any bladder cancer, you know, usually it causes blood as well. We'll see a bladder tumor when we go in there to take a look and then we go and we're infected and it comes back as squamous cell. So. You know, squamous cells are different cells. They're not actually found in a lot of them. There's some process of kind of transition into these cells and then they kind of will keep producing. But we find squamous cell usually in the setting of some type of chronic inflammation. And so for us in the U.S., that chronic inflammation is usually for patients that might have... chronic catheters. So if a patient, you know, some of our patients that have, don't have good bladder function, they have to use a catheter. So too, but they drain the bladder with either, either induolent permanently, or they're using it to drain themselves whenever they have to enter the bladder. And that can cause inflammation to the bladder. And at some point, you know, they can end up getting enough inflammation and inflammation can just wreak havoc to... you know, to form these cancers and that's often we see squamous cell cancer. So in other parts of the world, um, and I think that's kind of where, uh, Paul was alluding, and certainly in some Africa and Middle East, um, they'll see a lot more squamous cell, uh, carcinoma in the bladder. And that's because, uh, typically because they have, they're exposed to something called schistosoma, which is kind of a parasitic worm that's can get into their, you know, essentially it can, where it lives when someone's infected with it, it kind of lives in the lining of the bladder and it causes kind of chronic inflammation. That chronic inflammation can turn into cancer and that cancer tends to be squamous cells. So they see a lot more squamous cell. The third type that we sometimes want to see is adenocarcinoma. So adenocarcinoma calls more familiar with actually often see that in the bowel. but we will see some adenocarcinoma. And where that comes in is typically, we'll see that with what's called the urethra. So this is another kind of medical term, Mike, but your bladder, you have something called the urethra, where it is in development, the urethra is kind of part of the development of the bladder and it's... the remnants of it if they form cancer will be adenocarcinoma.

paul_roach:

So the difference like a transitional cell or squamous cell or adenos, they mean a lot to us as physicians, but what it means to the patient is these different cell types can behave differently and they can respond to treatments differently. So

charlie:

Yeah.

paul_roach:

if you're a patient, you're like, well, I got bladder cancer. You're not gonna worry, is it type A, type B or type C? but for your physician, we're gonna have to subtype it because a transitional cell, it's all the treatments that we've already talked about. The squamous cell, I don't know, I'm gonna guess it's a little more sensitive to x-ray therapy than transitional because other screams tend to be, but I don't know. An adeno, maybe there's certain chemo treatments that work better for it, I don't know. But that's kind of how it works.

charlie:

Yeah, so I would say, you know, for the most part of it, the early treatment is kind of the same. I mean, you're still doing kind of primary endoscopic resection, but yeah, the grading can be a little bit different. There's sometimes put a little bit higher risk. Some of the treatments, so squamous is not

michael:

Thank you.

charlie:

really sensitive to chemotherapy, and so it's, you know, often if we find squamous that... We will often, those patients will end up needing cystectomies.

paul_roach:

Oh, okay, so it's not sensitive. All right.

michael:

Well, to go back to Paul's nod to listeners in Africa, what can they do to kind of try and stay on the early side of things? Are there, if it's a parasitic thing or something, are there preventative measures that can be taken? Are there lifestyle things that can be done? Or is it still, you're relying on frequent... health checks with you know like we do here a yearly health check what can they do?

charlie:

So I mean, this is probably the most basic and I think every doctor is gonna tell you is the number one way to avoid bladder cancer is to not smoke cigarettes or if you do smoke, to quit. I mean, from an American and Western perspective, that's the, again, that's the highest risk factor. So that's kind of the number one. Beyond that, there's not much, you know, People that come in, we do sometimes see people with no prior smoking history and they come in with bladder cancer, sometimes even invasive bladder cancer. Some of it's just the luck of the draw. We all have our own genetic makeup and some people are just... There are certain people that are, because of their familial genetics, are more prone to cancer or just they've developed some type of mutation that puts them at risk. Nothing you can do about that. And so, we don't really make any terms of kind of lifestyle recommendations, other, beyond probably cigarette smoking is number one.

paul_roach:

Sounds like it's number one, two, and three.

charlie:

Yeah.

michael:

Well, the other questions that I always ask is if you do end up, uh, you know, at a late stage, um, one of the things that has come up in the other podcasts that we've done is getting into some kind of a, uh, uh, testing, uh, what do you call it, Paul?

paul_roach:

clinical

michael:

The

paul_roach:

trial.

michael:

clinical trial. That's it. Thank you. Is there anything like that that I would want to maybe keep my eye out for if I find myself with a, uh, kind of a later stage or more aggressive cancer.

paul_roach:

You know,

charlie:

Yeah.

paul_roach:

like other targeted therapies or monoclonal antibodies or anything else that they're experimenting with that you know about.

charlie:

Yeah, I mean, it's so like everything. And I think in the oncology world, a lot of it's, there's a lot of new immunotherapies. I mean, there are kind of systemic immunotherapies. We talked about BCG, but there's a lot of, you know, kind of immunotherapies that are being tried on for, for bladder cancer. You know, there's, there's PD-1 inhibitors, which, you know, that's kind of a. I've been cancer program death, Ligan, which I think that's what the PD stands for program that Ligan, but these are, these are targeted therapies that, uh, that they're using to kind of essentially, uh, target, uh, the genes that have kind of, I think kind of control. kind of the cancer pathways that lead to that. So there's a lot of targeted therapy that it's not standard of care, but that you will see probably in clinical trials. And I think probably when we get further down the road in the next 10, 15 years, we're gonna see more and more of that.

michael:

And that would probably be like, if I'm on that, in that sort of low grade, you could just sort of, um, scrape it off of the lining wall. I'm not going to be in that. But if I'm in that sort of next level where I might be at risk of losing the bladder, it's you were talking about some, some, uh, sort of strategies for helping, maybe letting me keep my bladder. Would that be where I would be most likely to look for this? Cause if it goes beyond that, you would just pretty much cut it out, right?

charlie:

Uh, so while most of these, well, yeah, to grow out of it right now, most of these, these more, these immunotherapies, targeted therapies are for a late stage metastatic disease where we don't have a, we don't have a good solution for, uh, right now, the standard of care for muscle invasive bladder cancer is to, to take the bladder out. Um, yeah, maybe, maybe it will, maybe we're heading in that direction where we can. you know, rather than taking the bladder out, we can give them some type of medication that will, that will essentially cure the cancer without the requirement to remove the bladder. You know, that's probably ultimately the goal. But right now in practice, I think those treatments are reserved for, for individuals that have metastatic disease and probably any guys that have had chemotherapy that have progressed on chemotherapy and that's where the trials come in place right now.

michael:

And if I were interested in learning more about any of those, even though they may be, you know, years down the road, where might I go looking for that?

paul_roach:

Well, usually what I'll do is I'll put into the show notes some links for that. You know, I usually reach right to National Cancer Institute and a few other favorite sites. So all they have to do, any listener can just log in and check out our show notes and I'll have a few links for that.

michael:

Excellent.

paul_roach:

Well, all right, Charlie, thank you very, very much for joining us today. Are there any saved rounds, any last discussion points that we wanna hit?

charlie:

I think it was a great discussion. I appreciate you having me on.

michael:

We appreciate

paul_roach:

We really

michael:

you

paul_roach:

appreciate

michael:

coming out.

paul_roach:

you. Yeah, thank you so much. All right, well, ladies and gentlemen, thanks again for listening. And if you have a topic you would like to have us discuss or comments or feedback, please either log on to www.PaulBrianRoach.com. That's Brian with a Y and Roach like the bug, P-A-U-L-B-R-Y-A-N-R-O-A-C-H.com and click on the about and contact page or send them directly to letters at PaulBrianRoach.com. And once again, thank you, Charlie Reinhart, MD, and Michael Reardon. Much appreciated.

michael:

Excellent.

charlie:

Yeah,

michael:

Thanks,

charlie:

thank you.

paul_roach:

All right.