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Bladder Cancer: Overview

Bladder cancer is also known as urothelial carcinoma. Urothelial cells line the urinary tract, including the urethra, bladder, and ureters and renal pelvis in the kidneys. These urothelial or transitional cells are in contact with urine. Bladder cancer happens when those cells in the bladder start to grow out of control.

Smoking and being exposed to secondhand smoke increases the risk of developing bladder cancer. In addition, people exposed to occupational or environmental chemicals may have a higher risk of developing bladder cancer. White people are twice as likely to develop bladder cancer as are Black people or Hispanic people, and older age is another risk factor. Health history also matters, with chronic bladder inflammation, such as urinary tract infections or kidney stones, as well as a personal or family history of bladder cancer, associated with risk of the disease.

Many people are unaware of the common signs of bladder cancer, such as blood in the urine, known as hematuria. If blood in the urine can be seen, this is called gross hematuria. When a physician runs a urinalysis test as part of a routine checkup, tiny amounts of blood may be detected. This is microscopic hematuria. Any blood seen in the urine should be checked by a physician. Irritation when urinating, urgency and frequency are other warning signs. These signs may also be from other causes, such as a urinary tract infection, kidney stones or aging.

Bladder Cancer: Living with Cancer

Bladder cancer has a high rate of recurrence, which implies the need for regular surveillance with cystoscopy over the course of a patient’s lifetime. For some patients, the new normal after bladder removal surgery is adjusting to life with a urinary diversion. A patient should always feel comfortable talking with their health care team about any issues or questions. If the team can’t help, they can usually find someone who can.

Bladder Cancer: Types of Disease

Doctors usually describe and treat bladder cancer by how far it has grown into the bladder wall.

NMIBC (non-muscle invasive bladder cancer) is cancer that remains in the urothelial cells that line the bladder.

MIBC (muscle-invasive bladder cancer) is cancer that has grown into the deeper layers of bladder muscle.

If bladder cancer has spread to other parts of the body outside the urinary tract, it is advanced disease, or metastatic.

Types of bladder cancer include urothelial carcinoma, squamous cell carcinoma, adenocarcinoma, small cell carcinoma and sarcoma.

Urothelial carcinoma, the most common type of bladder cancer, is also known as transitional cell carcinoma. Transitional cell carcinoma begins in the part of the kidney, called the renal pelvis, where urine collects before moving to the bladder.

Squamous cell carcinoma comprises 1% to 2% of bladder cancers, according to the American Cancer Society. Most squamous cell carcinomas of the bladder are invasive.

Adenocarcinoma, which are also mostly invasive, occur in only 1% of bladder cancers.

Small cell carcinoma, which occurs in less than 1% of bladder cancers, start in the neuroendocrine cells. This subtype of the disease can grow quickly.

Sarcoma of the bladder is rare, and start in the muscle cells of the organ.

Bladder Cancer: Diagnosis

A urologist will make a bladder cancer diagnosis. Urologists use a cystoscope to examine the lining of the bladder and the tube that carries urine out of the body (urethra).

If bladder cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out whether the cancer has invaded the bladder wall or spread beyond that, and, if so, to what parts of the body. Grade refers to how abnormal the cancer cells look and how many cells are multiplying. A higher grade means the cells are more uneven and are multiplying more. Knowing the grade can help your doctor predict how quickly the cancer will grow and spread.

Bladder Cancer: Treatment

When bladder cancer is classified as NMIBC, surgery to remove the tumor is often the first step. A transurethral resection of the bladder tumor uses a special instrument inserted through the urethra to remove the tumor. If the tumor is low risk/grade and has not invaded the muscle wall of the bladder, it may not require more treatment. Unfortunately, bladder cancer has a high rate of recurrence so most of those who receive diagnoses must return to their urologist at regular intervals for surveillance using cystoscopy to see if the tumors return.

If the tumor cells appear aggressive under the microscope and the pathologist determines that the cancer is high risk/grade, it is more likely to return or worsen. In these cases, further treatment to keep the cancer from returning or worsening is required. Most often, patients with high-grade NMIBC receive intravesical (inside the bladder) treatments. Bacillus Calmette-Guérin (BCG) is an early form of immunotherapy that uses a weakened form of bacteria. When these bacteria are put into the bladder, the immune system goes on alert. It responds by killing cancer cells on the bladder lining. Though BCG is very effective, it doesn’t work for all tumors. If BCG doesn’t work, there are other options such as mitomycin C, an antibiotic that helps fight tumors.

When bladder cancer grows into the deeper layers of the bladder (MIBC), it is more difficult to treat. In many cases, a urologist may suggest radial cystectomy, which is surgery to remove your bladder. Removing the bladder also involves removing lymph nodes around the organ. As part of the surgery, it will be necessary to create a urinary diversion, a new way for urine to leave your body.

Systemic chemotherapy is medicine that treats cancer throughout the whole body. Neoadjuvant chemotherapy is chemotherapy patients get before bladder removal surgery. Clinical trials have shown that cisplatin chemotherapy before bladder removal improves survival for patients with MIBC because it helps kill bladder cancer cells that may be outside the bladder. Adjuvant chemotherapy is the chemotherapy patients get after surgery.

Recently approved targeted therapies can block the growth and spread of cancer. They focus on stopping the cancer-driving activity caused by specific genetic mutations that are found in some bladder cancers.

Some patients may benefit from combined modality therapy, which uses surgery to remove the tumor, plus chemotherapy and radiation to help kill the cancer while keeping the bladder intact. This option can be used for some patients who are ineligible for bladder removal surgery. Those with advanced or metastatic disease may benefit from chemotherapy and a variety of immunotherapies that can help the body fight off the cancer.

There are many talented researchers and clinicians working to improve the diagnosis and treatment of the disease. Clinical trials are an essential part of bladder cancer research. They may provide treatment alternatives to patients who have not had success with standard and approved therapies.

Breast Cancer: Living with Cancer

Similar to other cancers, there is often a fear breast cancer will return, and in some individuals, the cancer will never go away completely. Therefore, it is key to maintain follow-up appointments for physicians to watch closely. These include consistent doctor appointments, mammograms, pelvic exams, bone density tests, as well as we blood and imaging tests.

Survivorship care plans, comprised of a suggested schedule for follow-ups, a list of long-term effects, lifestyle modification suggestions and a summary of ones diagnosis, may be very helpful for long-term care and to aid individuals in transitioning back to a primary care provider.

Breast Cancer: Types of Disease

The type of breast cancer that is diagnosed is determined by specific cells.

Ductal carcinoma in situ, or DCIS, also known as intraductal carcinoma, is when the abnormal cells have not spread through the ducts into surrounding breast tissue. It is a non-invasive breast cancer that has not spread outside of the breast; however, it can become invasive.

Lobular carcinoma in situ, also called lobular neoplasia, is when the abnormal cell growth starts in the lobules of the breast and has likely not spread to surrounding tissues. This subtype can be an indicator for the likeliness of developing invasive cancer in either breast.

Invasive ductal carcinoma, also known as infiltrating ductal carcinoma, is the most common type of breast cancer that occurs when the cancer starts in the ducts of the breast, then grows into fatty breast tissue. This type of breast cancer may spread to other parts of the body.

Invasive lobular carcinoma, also known as infiltrating lobular carcinoma, starts in the lobules of the breast. As one of the less common types, invasive lobular carcinoma may be difficult to detect via mammogram.

Inflammatory breast cancer, an uncommon type of invasive breast cancer, occurs when the cancer cells block the lymph vessels in the skin, causing inflammation, redness, pitted appearance, itchiness or tenderness. In this instance, a lump may not be detected

Paget disease, also rare, starts in the ducts and spreads to the skin of the nipple. Symptoms include crusted, scaly, red, bleeding, oozing, burning or itchy nipples.

Lastly, there are subtypes of breast cancer driven by hormones that will drive treatment decisions: hormone receptor-positive, HER2-positive and triple-negative breast cancer.

Breast Cancer: Diagnosis

After a biopsy or surgery to remove the breast cancer, a pathologist examines the tissue and may run additional tests to create a pathology report to help create an appropriate treatment plan for the patient. In addition, the use of an Oncotype Dx® Recurrence Score results may also be considered and used to determine certain treatment.

Stage 0, carcinoma in situ, is the earliest stage of breast cancer, followed by:

Stage 1: The tumor is 2 centimeters or smaller; the cancer has not spread outside of the organ; or small clusters of cancer cells are found in the lymph nodes.

Stage 2: There is no tumor, or the tumor is smaller than 2 centimeters, but the cancer is also found in the lymph nodes or the breast; or the tumor is larger than 2 to 5 centimeters, but the cancer has not spread to lymph nodes.

Stage 3: There is no tumor, or the tumor can be any size, but the cancer has spread to the lymph nodes; the tumor is larger than 5 centimeters and small clusters of cancer cells are found in the lymph nodes or the breast; or the tumor is larger than 5 centimeters and the cancer has spread to the lymph nodes.

Stage 4: The cancer has spread to other parts of the body, often in the bones, lungs, brain or liver.

When determining the stage of breast cancer, key pieces of information include the size of the tumor, its spread to nearby lymph nodes, metastasis to other parts of the body, grade of the cancer, as well as estrogen receptor, progesterone receptor and HER2 status.

Breast Cancer: Overview

Breast cancer, which occurs when cells grow out of control, can start in one or both breasts, in different parts of the organ – lobules, ducts, nipple, fat and connective tissue, blood vessels and lymph vessels.

Although most common in women, men can get breast cancer, too

Signs of breast cancer can include a lump in the breast or arm pit, a change in shape or size of the breast, nipple changes or discharge, and skin changes to the breast.

Risk factors for breast cancer include binge drinking, being overweight, especially after menopause, living a sedentary lifestyle and an unhealthy diet, which are all changeable lifestyle factors. In addition, unchangeable risk factors include female gender, older age, genetics, family history of the disease, personal history of the disease, race and ethnicity, dense breasts, benign breast conditions, exposure to diethylstilbestrol, menstruation, menopause, previous chest radiation and recurrent breast cancer.

Screening for breast cancer includes breast self-exams, clinical breast exams by health care providers and mammograms.

Although breast cancer can be confined to the breasts, it is possible for the cancer cells to invade the bloodstream or lymph system, traveling to other parts of the body, causing spread, or metastasis.

Breast Cancer: Treatment

Each breast cancer subtype has a unique set of features that drive cancer growth, division and multiplication. Therefore, each type of breast cancer is not treated the same. Common treatment options include surgery, chemotherapy radiation or systemic therapies.

Surgeries to remove breast cancer include breast-conserving surgery, which removes the cancer as well as some surrounding normal tissue, or a mastectomy, in which the entire breast, including tissue, is removed. On the other hand, surgery to remove nearby lymph nodes includes sentinel lymph node biopsy, where a dye is injected in order to remove only the lymph nodes under the arm that have taken the dye, or an axillary lymph node dissection, where many lymph nodes are removed from the underarm.

Depending on the stage of the disease, radiation can be used after breast-conserving surgery, after a mastectomy or if the cancer has spread to other parts of the body. Similarly, chemotherapy may be recommended before or after surgery, and to treat metastatic disease.

Because some types of breast cancer are affected by hormones, treatment to stop such hormones from attaching to proteins that helps the cancer grow, hormone therapy may be used. This type of therapy is typically administered after surgery; however, sometimes it is started prior to the procedure. It can also be used to treat breast cancer that has recurred or metastasized.

Targeted therapy is used for certain types and/or stages of breast cancer. For those with HER2-positive breast cancer, targeted therapies include antibody-drug conjugates, kinase inhibitors and monoclonal antibodies. For those with hormone receptor-positive breast cancer, the use of CDK4/6 inhibitors, mTOR inhibitors and PI3K inhibitors are all considered. For those with triple-negative breast cancer, antibody-drug conjugates in combination with chemotherapy would be considered. Individuals who test positive for the BRCA mutation can also be treated with PARP inhibitors.

In addition, immunotherapy, such as immune checkpoint inhibitors, maty be used. For example, it can be used in combination with chemotherapy to treat those with triple-negative breast cancer, either before or after surgery, to treat breast cancer recurrence or disease that has spread to other parts of the body.

Gastrointestinal Cancer: Types of Disease

Gastrointestinal cancers can develop in a variety of organs, and include:

The most common types of gastrointestinal cancer are esophageal, stomach, colorectal, pancreatic and liver.

Gastrointestinal Cancer: Living with Cancer

Similar to other cancer types, a gastrointestinal cancer diagnosis, treatment and survivorship can come with a variety of emotions. Staying diligent with one’s care and follow-up appointments is key.

Moreover, to lower one’s risk for cancer recurrence or to negate any long-term effects, exercising, eating a certain type of diet or taking nutritional supplements may help.

Lastly, the GI Cancers Alliance, or GICA, have a number of advocacy groups to aid in living with a gastrointestinal cancer diagnosis.

Gastrointestinal Cancer: Treatment

Among the most common gastrointestinal cancers, treatment options vary. However, what is consistent across the different cancer types is the utilization of a multidisciplinary approach to care, which can include a medical oncologist, surgeon, gastroenterologists, radiation oncologists, and more.

Treatment options for colorectal cancer include surgery – including laparoscopic surgery, colostomy, radiofrequency ablation or cryoablation – as well as radiation, chemotherapy, immunotherapy and targeted therapies.

Similarly, esophageal cancer can be treated with surgery, radiation, chemotherapy, immunotherapy and targeted therapy, as well as endoscopic treatments like endoscopic mucosal resection, photodynamic therapy, radiofrequency ablation, laser ablation, argon plasma coagulation, electrocoagulation and esophageal stent.

For pancreatic cancer, the best option may include more than one type of treatment, comprised of surgery, ablation or embolization, radiation, chemotherapy, targeted therapy and immunotherapy.

Treatment for stomach cancer is dependent on stage, age, overall health and personal preferences. Typically two or more treatment options – including surgery, chemotherapy, targeted therapy, immunotherapy and radiation – will be used.

Gastrointestinal Cancer: Overview

A tumor can form in the gastrointestinal tract, a 25-foot pathway starting from the mouth to the anus, after a change in DNA causes abnormal cells to grow.

According to Yale Medicine, gastrointestinal cancers are more likely to develop in men, and risk for the diseases increases with age. Other risk factors include smoking, alcohol consumption and an unhealthy diet, as well as underlying conditions like gastroesophageal reflux disease in the esophagus, Helicobacter pylori infection in the stomach, diabetes in the pancreas, inflammatory bowel disease in the large intestine, and hepatitis B or C virus infection or cirrhosis in the liver. Meanwhile, a small percentage of these cancers can be associated with family history or genetics.

Symptoms of gastrointestinal cancers depend on the type of cancer, and often may not occur until the disease has become more advanced.

Gastrointestinal Cancer: Diagnosis

If gastrointestinal cancers are suspected, the following may be conducted:

Endoscopy or esophagogastroduodenoscopy: evaluates the lining of the esophagus, stomach and small intestine for tumors.

Colonoscopy: checks the colon and rectum for polyps.

Lab tests: searches for changes I the blood.

Imaging: including MRI, X-Ray, ultrasound, CT or PET scans, looks for abnormal tissue in the digestive system.

Biopsy: evaluates sample obtained for cancer cells.

Gynecologic Cancer: Diagnosis

Unfortunately, only cervical cancer has routine screening tests using Pap smear and HPV testing. If medical history or a physical exam require further testing, diagnostic tests for gynecologic cancers include blood tests, a pap test and imaging tests, and a biopsy would be necessary to confirm.

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