Fighting Cancer: A Survival guide

What is cancer?
Cancer is a disease when specific cells within the human body rebel against the system and start to multiply out of control until they spread and ultimately cause death.

This week, we will focus on Bladder Cancer, which is one of the commonest and most lethal cancers.
Of course, there happens to be various degrees of cancer. To simplify matters for my patients, I try to give them the following example: When a person is very good, he does not change into being somebody extremely bad overnight. First, he becomes less good and then gradually he continues to worsen until he becomes so bad.
Therefore, it should be our aim to intervene as early as possible to prevent the situation from worsening.
This maybe an oversimplification but it is quite typical of how Bladder Cancer acts especially with regards to how these tumours progress to more lethal types if left untreated, or even if treated incorrectly.

What is the Urinary Bladder?
The bladder is an expanding and contracting muscular bag located in the pelvis of both sexes. The kidneys produce urine which is passed down into the bladder via the ureters. Here, the bladder acts as a storage reservoir for urine until it exits the body.

Who are at risk of acquiring Bladder Cancer?
Bladder Cancer affects three times more men than women. It is more common in the elderly and is rarely seen below the age of 40 years.
People employed in certain chemical industries have higher chances of developing Bladder Cancer. Smoking also has a very strong link to this disease and as a matter of fact, smokers have double or triple the risk of developing Bladder Cancer compared to non-smokers.
In a few studies, excessive coffee consumption has also been associated but a lack of a strong relationship compounded by the fact that coffee drinkers have a tendency for smoking has further weakened this association.
Even artificial sweeteners had been once linked to Bladder Cancer in experimental animals. However, no such association has been proven in humans. Ongoing scientific research is proving a strong genetic link to this disease.

What are the symptoms?
The main symptom of Bladder Cancer is blood in the urine. This blood can be either microscopic or visible to the naked eye.
Of course there can be many less serious causes for blood in the urine, such as urinary infections or urinary stones for example. However, the passage of bloody urine without pain should be considered to be due to cancer until proven otherwise.

What investigations should be done?
Therefore, further investigation by a urologist is warranted for both painful or painless bloody urine.
Confirmation of blood in the urine is performed by microscopic examination. The urine can also be examined for cancer cells that may have been shed off.
Another important tool is an ultrasound scan. This is a harmless procedure where the urinary system can be examined with the aid of sound waves. This scan helps to detect any urinary cancers and is totally harmless and carries no risks of radiation.
Following these tests, the patients bladder should be inspected from the inside using a small camera called a cystoscope.
This device is passed up from where urine exits the body until it enters the bladder. OUCH! Sounds painful, but it actually is a quite painless procedure.
The cystoscope allows us to visually examine the bladder and take a biopsy from any suspicious part of the bladder.
The biopsy is then sent to a doctor specialising in microscopic diagnosis of diseases known as a Histopathologist. At this point, he can comment whether this tumour is the kind that spreads (cancer) or not (benign).
In addition, he should also be able to tell us how much the probability is, or tendency, for it to spread. Based on this information, the Urologist can then advise the patient on the most suitable treatment in their particular case.

How is this disease treated?
When looking into the bladder with a cystoscope, all the inner surfaces or walls of the bladder have to be meticulously examined.
Bladder tumours usually look like sea weed or cauliflowers.
Urologists can then remove these tumours with an instrument called a resectoscope. This is basically similar to cystoscope but has an added capability to remove these tumours by cutting them out using an electric current.
Sometimes, however, no bladder tumours can be detected despite the patient having the signs and symptoms of this disease.
The reason being that the tumour tends to take a carpet-like form making it difficult to differentiate it from the normal bladder lining. Even though these tumours tend to be pre-cancerous, they have a higher tendency for changing into a vicious form of bladder cancer.
Naturally, because these forms were more difficult to detect, a delay occurs in diagnosing them. As a result, they became more aggressive and progress into a more dangerous form of bladder cancer.

New diagnostic techniques
Recent developments, however, may change the prognosis in these previously difficult to diagnose cases by detecting the cancer at a much earlier stage.
This development has come in the form of a new pharmaceutical product called Hexvix which is aimed at improving visual inspection of the bladder by tumour fluorescence.
When this solution is instilled into the bladder and kept for a period of one hour, it is taken up only by cancer cells.
When it is later subjected to a blue light during cystoscopy, the cancers cells give off a pronounced psychedelic red immuno-fluorescence in comparison to the surrounding normal tissue which will remain blue.
Therefore, not only has Hexvix made cancer detection easier but it has also ensured that doctors achieve adequate safety margins after removing the cancers because even the tissue that looked normal under white light, gives off a red immuno-fluorescent glow when using Hexvix in combination with a blue light.
This reduces the chances of leaving small foci of cancer cells that may progress once again.
Our hospital was one of the first centres in Germany to provide this treatment for our patients and as a result we are detecting more bladder cancers at earlier stages.
 In addition, we are having less recurrences of the disease due to better resection margins. In a nutshell, it has made a difference of seeing or not seeing the cancer as you can see for yourselves in the photos.

Is any surveillance required after treatment?
It must be mentioned, that bladder cancers have a tendency to recur even if they are excised.
Therefore, periodic follow-up visits are arranged to look inside the bladder to ensure there are no recurrences. In certain types of bladder cancers, special cancer fighting drugs can be instilled directly into the bladder.
These drugs help to prevent recurrences or at least slow down the time it takes for them to recur. It is left up to the judgement of Urologist, which patient would actually benefit from this form of treatment.

What about treatment of advanced cases?
However, in cases that do not respond to this form of tumour resection, a more definitive procedure is required to secure a better prognosis for the patient.
This is because, it becomes impractical to repeatedly resect the bladder in this way because you will not be able to ensure that the tumours do not invade deeper layers of the bladder as well as the lymphatic system. Remember, the deeper the cancers roots are, the higher the likelihood for spreading to other parts of the body.

If the bladder must be removed, how would we pass urine?
In these cases, the whole bladder must be removed. In males, the prostate gland is also removed simultaneously while in the females, the uterus and ovaries are also removed simultaneously during this procedure. However, this still leaves us with the problem of storing the urine as well as how to let the urine exit the body.
In the past, the ureters which transport urine from the kidneys to the bladder were inserted into a special tiny pouch created from the intestines.
This pouch would in turn be brought to the surface of the skin where it was attached to a bag.
Of course, this was not a very sightly procedure and entailed emptying this bag several times per day. However, it did cure the patients of their cancer and gave them a new lease of life.

Are there any operations that remove the bladder while preserving the dignity of the patient?
Doctors, however, are never satisfied if their patients are not fully satisfied and that is why they continue to strive for excellence in treatment modalities.
This is why a newer procedure called the NEO-Bladder (meaning new bladder) has been developed.
In this operation, a bladder is fashioned from the patients intestines.
The ureters bringing urine from the kidneys are inserted into this new bladder which is then positioned in the site of the original bladder.
In these cases, patients are able to pass urine from the same place they always had.
This prevents the social and psychological stigmata the patients faced with the older techniques. Now they feel more comfortable in public and even in private with their partners.
Next week, I will be flying to Cancun, Mexico to present our results of a modified NeoBladder called the BERLINER NEOBLADDER at the International Uro-Gynecology Association IUGA Annual Meeting.
The Berliner Neobladder was developed in our hospital and uses titanium coated materials to safeguard against complications seen in previous Neobladder techniques. We are seeing excellent results especially with regards to quality of life.
One must remember, it is not only a matter of treating the cancer, but treating the patient as well.

Is there anything people can do to fight this disease?
I will leave you now with the following message: As with any cancer, the earlier you detect Bladder Cancer and commence the appropriate treatment, the better the outcome.
Please, please, please consult your doctor immediately when you develop something abnormal.
You have nothing to lose except the time waiting to see the doctor.
However, you gain the benefit of earlier diagnosis & better outcome if a disease is detected. If no disease is detected, you would have been at least reassured about your current health status.
Unfortunately, we see so many patients that could have been saved but due to late diagnosis very little could be done.
Therefore, I kindly request you to collaborate with doctors in this fight against cancer by having an awareness of these lethal diseases.
In addition, cancer associations world-wide are always in need of your charitable efforts so please contribute your time or money whenever possible.

Can we send in any questions or comments?
Please bear in mind that this is a simplified explanation of Bladder Cancer.
Therefore, if you have any specific questions or comments related to this, you are welcome to contact me on drelansari@hotmail.com
We may even print answers to these in GulfWeekly for the benefit of all our readers.