Actos Cancer: The popular diabetes drug Actos has been linked to cancer. If you took Actos and Later developed Bladder Cancer, please contact us today and we will arrange a free consultation with an attorney about your potential Actos Cancer Lawsuit
 

Information from other sources about Actos Cancer

After the initial shock of being given a new diagnosis of Actos Cancer, a flood of emotions follow with fear and anxiety being foremost. Questions fill your mind:

How serious is it?
Can 1 be cured?
Am I going to die?
Will I suffer?
What treatments are available?
Can 1 do anything to improve my odds?
What side effects will occur from the treatments?
Will I lose time from work?
Will my insurance cover the cost?
Will I be disfigured?
Will my spouse and family be supportive?
Do I have a good doctor?

Actos Bladder Cancer, or any serious potentially life threatening illness is generally alien to most individuals. Suddenly, lives are changed and a new reality must be dealt with. Becoming a “patient” or worse “a cancer patient” is not only threatening, but a dreaded proposition. Cancer patients are not happy with the loss of autonomy, the invasion of privacy, the discomfort inflicted upon them and the demands on their time and quality of life. As a patient, being thrust into this altered identity, it is essential to seek out the information you need. Having a fundamental base of knowledge is a must when facing the issues and treatment decisions which lie ahead. In the following pages, together we will explore Actos Bladder Cancer, a disease which is totally foreign to most of us until the diagnosis is made. I have chosen to present the information in a question and answer format, written in a conversational tone, as if I were having an extended consultation with one of my patients. The questions are typical of what individuals have asked over the years. 1 have covered the key issues and decisions the individual with Actos Bladder Cancer may face. The answers are to the point and cover the essentials required to make an informed decision for most individuals. For others, a more detailed resource may be required. For helpful sources of additional information see the Appendix.

Each individual’s situation is unique. Decisions on treatment may be modified based on the patient’s preferences and values and altered by other considerations such as age and coexisting conditions. By becoming an individual knowledgeable of Actos Bladder Cancer, you will be prepared to fully partner with your physician for your best possible outcome. To your companions and family members, this book will serve to answer the many questions and doubts that may arise. Having your loved ones informed and supportive is a big plus for the individual facing this new challenge.
The book is written in a logical sequence starting with finding a qualified urologist to the basics on Actos Bladder Cancer, its assessment and treatment. At the end of the book, you will find chapters on complementary medicine, advance care planning, and hospice care. The book can be read in sequence or each chapter can serve as a resource covering the basics of the topic. It is my hope this book will help clarify the many issues and options individuals must face with Actos Bladder Cancer. For family members, significant others and concerned friends, this resource should help improve your understanding and thus your ability to assist your loved one.

Understanding Actos Bladder Cancer is a tremendous first step that will assist you in your treatment. Having a qualified urologist administer the actual treatments and care for you is essential for the best possible outcome. In the following chapter, we will explore what you need to know to assure you have the right urologist.
BESIDES LEARNING ABOUT MY DISEASE, WHAT IS MY MOST IMPORTANT FIRST STEP?
Make sure you have an excellent urologist supervising your care. A urologist is a surgical specialist trained to care for conditions involving the male and female urinary tracts and the male reproductive system. The bladder is part of the urinary system, and a urologist is trained to care for problems involving it, including cancer.
IS IT IMPORTANT TO HAVE A BOARD CERTIFIED UROLOGIST?
A urologist board certified by The American Board of Urology has gone through an accredited urology training program (generally a four year program), following two years of internship and residency in surgery after four years of medical school. The urologist must be in practice after training and provide a detailed list of surgeries, including complications, over a twelve month period. The doctor will then take a two day oral and written test covering a wide spectrum of urology. If he passes, he is certified for a period of ten years. At the end of the ten year period, he must recertify to maintain his board status. Recertification entails a three month surgical and procedure log and a written test as well as reference letters from those in a position to judge the practicing urologist’s work. Any malpractice or judgments are also reviewed. Although being board certified does not guarantee you have an excellent urologist, it demonstrates that he has the fund of knowledge to practice urology competently. Even though board certification is voluntary, in today’s competitive environment more and more hospitals and insurance plans are requiring their specialists to be certified.
HOW CAN I TELL IF MY UROLOGIST IS BOARD CERTIFIED?
The urologist has worked hard to obtain board certification. The certificate from The American Board of Urology is often displayed openly in his office. If you do not see it, you can simply ask him or you can call 1-866-275-2267 or use this web site: www.certified doctor.org
SHOULD I TRY TO FIND A UROLOGIST WHO HAS BEEN IN PRACTICE FOR YEARS OR A NEWLY TRAINED ONE?
Surgery is a skill which can only be mastered with experience. The saying “practice makes perfect” definitely pertains to surgery. Although a urology training program offers the new physician years of training, his surgical skills will continue to improve with further experience. However, each individual physician has his own innate skills. Some more quickly learn and are simply better at the technical craft of surgery than others. For the most part, urologists finishing an accredited urology program have the training and skill set required to care for patients with Actos Bladder Cancer.
Experience also counts. As a physician practices the art of medicine, his depth of knowledge and ability to treat grows. Ask your physician how long he has been treating patients with Actos Bladder Cancer. If you require major surgery ask how many he has performed and if his complication rate matches what is expected.

Physicians by and large do improve as they practice, and all physicians are required to show that they are continuing to learn by partaking in continuing medical education, a requirement to remain licensed. Most physicians are compulsive in their medical practice and care deeply in the care they deliver. They continually strive to improve.
Some physicians may become “burned out” over the years as they continue to face the pressures of a busy medical practice. Similarly, towards the end of a surgeon’s career, technical skills may slip due to aging. New urologists are trained in the latest techniques and are familiar with recent medical literature, but may lack practical experience. In the end, recommendations from others and reputation may be your best guide to finding a qualified physician.

Ideally, you should have a competent, technically skilled surgeon who is also approachable and compassionate. You should be able to freely ask questions pertaining to your disease and treatment. Your physician should answer your questions forthrightly. Although some patients prefer a surgeon who will take over all aspects of care with no questions asked, most prefer in depth explanations, especially when alternatives exist and risks are involved.
Your urologist must be an individual who takes your concerns, priorities and values seriously. Your urologist should be a good communicator. It is his responsibility to keep you fully informed of your progress, make you aware immediately if things are not going well, and educate you fully in treatment alternatives. Your specific values should be incorporated into the decision process if alternatives are available. Even if your urologist makes a recommendation and you choose an alternative course (unless you are putting yourself in extreme jeopardy), he should honor your choice and continue his care of you. Becoming an educated patient will make your decision making process easier. Granted, your physician should provide you with the basics, however having time to review and digest the material will allow you to fully understand and accept your treatment regimen, providing you with peace of mind.

Beware of the physician who bombards you with statistics and studies and leaves the decision making to you. After all, you are not a physician and don’t have the practical hands on experience he does. Your physician should provide the facts and the statistics, guide you through the information, and make treatment recommendations based on your preferences.

You may find yourself emotionally distraught and overwhelmed. Having a physician on your side is invaluable. You should be able to trust your physician. Complete honesty on the part of your doctor in his care of you is a must. From the doctor’s point of view, trust is also a necessity. Physicians have an extremely difficult time dealing with individuals who do not trust them. Without trust, the physician patient relationship is extremely hindered.

Lastly, your urologist should be compassionate. Having cancer is tough enough, you shouldn’t have to deal with a rude or arrogant physician. Your urologist should be supportive at all times. He should treat you as an individual and not just as “another cancer patient.” People with Actos Bladder Cancer will require long term follow up and care. Having a compassionate individual to work with will make a tremendous difference
HOW DO I FIND A GOOD BOARD CERTIFIED UROLOGIST?

A good starting point is your primary care physician. He will generally have a number of specialists to whom he generally refers his urology patients. If the primary care physician has been working with these urologists, he should have an appreciation of their skills and temperament. However, this does not mean he is referring you necessarily to the best available urologist in your area. His choices may be limited by insurance or hospital networks. An excellent source of information would be nurses who work in the operating room, recovery room or on the surgical floor where the urologist does his surgery. Asking friends or other individuals who have had experience with the urologist can also prove useful. After a little digging, you can often quickly learn what type of reputation the urologist has in the community. Generally, if an established urologist has a “good reputation” this is an indication that he has pleased many individuals with his care.
SHOULD I CHECK TO SEE HOW MANY TIMES MY UROLOGIST HAS BEEN SUED?
Given the litigious society we live in, most physicians can face at least one malpractice lawsuit during their careers. In urology, two of the most common causes of litigation would be a surgical mishap leading to a complication, or failure to diagnose cancer in a timely fashion.
Medicine is based on science, but also is an “art.” Individuals do not walk into their physicians offices with a diagnosis and treatment plan always readily apparent. Even the best intentioned, thorough physician will make mistakes. Most of these errors do not result in harm. On occasion they do, and a law suit may follow. If a physician develops a good working relationship with a patient, these bad outcomes more often than not are acknowledged and accepted without legal entanglement. Competent, busy physicians may be dealing with a higher mix of complicated patients, leading to a higher number of potential suits. Physicians who have poor “bed side manner” may find themselves dealing with more suits. If a physician has an inordinate number of suits, “red flags” should go up, as competency may be an issue.

For those individuals who wish to check out the malpractice history of their physician, you may request an inquiry from the National Practitioners Data Bank at: 1-800-767-6732 or check the web site: www.npdb-hipdb.com

MY FAMILY WANTS ME TO GO FOR TREATMENT OF MY ACTOS BLADDER CANCER TO THE “TEACHING HOSPITAL” IN THE CITY MY LOCAL UROLOGIST IS COMPETENT AND CARING AND I TRUST HIS JUDGEMENT SHOULD I LISTEN TO MY FAMILY AND SWITCH UROLOGISTS?

As we have discussed in the preceding questions, finding an excellent urologist to partner with is a must. A physician established at a “teaching hospital” (a hospital where physicians are trained in their respective fields of specialty) is at the minimum, competent. A large teaching or academic center would not risk its reputation on an individual who is sub par. Some individuals may be world class surgeons, but not all will be. An individual may be an average surgeon, but a gifted teacher or researcher, making them invaluable to their academic center. Your local community urologist will likely be an individual trained at one of these academic teaching hospitals. In addition, community hospitals also have credentialing and quality review programs to weed out incompetent physicians. In general, it is true the academic center will have more stringent standards and review of their staff. Nevertheless, excellent physicians can be found at the community hospital as well.

ISN’T IT TRUE THAT ACADEMIC OR TEACHING HOSPITALS WILL HAVE THE BEST TECHNOLOGY OR MOST UP TO DATE INFORMATION TO TREAT MY CANCER?

These hospitals generally are at the forefront of innovation regarding technological advances, testing and implementation of new surgical techniques and chemotherapeutic regimens. However, no one center can be excellent in all spheres of medicine. Each will have particular strengths and weaknesses. We are however, fortunate medical knowledge and innovation are shared openly via medical journals and conferences and other means of information exchange. New information and proven effective techniques are rapidly disseminated throughout the medical community. Some teaching hospitals may be “centers of excellence” for a particular procedure or innovative approach that is available at only a few sites in the country. There is naturally a lag time for some procedures to spread to the local level, and if in fact a new procedure carries substantial benefits compared to the standard, and is not available locally, then a referral may be appropriate.

Medical information is scrutinized in journals and reviewed at conferences. The newest treatment regimens for advanced cancer are explored in clinical trials to determine their efficacy and safety. It is only after they are proven that they become adopted as standard practice by most physicians. For the vast majority of individuals with Actos Bladder Cancer, excellent, comprehensive treatment can be obtained at the local level. For those requiring more specialized care or for those unfortunate individuals with advanced cancer who desire experimental therapy via a clinical trial for their cancer, a referral to the appropriate center may be appropriate.

IF I HAVE MY MAJOR SURGERY PERFORMED AT A TEACHING HOSPITAL, WILL THE ATTENDING PHYSICIAN PERFORM MY SURGERY AND TAKE CARE OF ME AFTERWARDS?

At a teaching hospital, physicians are in training to master their skills before going out into “practice” in their respective fields. Interns are fresh out of medical school with limited practical training. Often they are referred to as PGY 1 (post graduate year 1). Years of training follow (PGY2, PGY3 etc.). Urology residents are required to generally have at least two years of training in a surgical program followed by four years in urology residency. It is the responsibility of the residency director to provide adequate training for these future urologists while assuring patient safety. Practically speaking, there are usually one or more attending physicians who supervise the work of the physicians in training. The attending physicians are board certified, experienced physicians who treat patients while simultaneously training physicians. The residents will be a key component in your care. They will be assessing you both pre- and post-operatively and will be writing orders directing your care. How much of the surgery they get to do is dependent on their years of training and their skills. They will be under the direct supervision of the attending physician. If you have concerns, you should address them with your attending physician.

Given the monetary pressures in today’s medical practice, some physicians are over booked and cannot see the allotted number of patients scheduled without delays. The theory behind this schedule is the expectation that a number of patients will not show for their appointment, allowing the physician to stay true to the schedule and not fall behind.

However, sometimes all of the patients do show, and the physician is delayed. Even with a carefully thought out schedule, emergencies may arise and some visits unexpectedly take longer than scheduled. The physician wants to devote the time and attention required for each individual. After all, you also expect the same time and attention during your visit. Even the most conscientious physician may find himself running behind in a busy medical practice. This lateness should be recognized by the physician who will often acknowledge it with an apology. If you find it distressing to wait more than fifteen minutes (a reasonable time to wait), you should discuss your feelings with your physician, who often can arrange an appointment at the beginning of the schedule when he will almost be guaranteed to be on time.
WILL THERE BE OTHER PHYSICIANS INVOLVED IN MY TREATMENT OF ACTOS BLADDER CANCER?
You may need to be referred to an oncologist, a physician specialist in the medical therapy of cancer. At times, a referral to a radiation oncologist, a specialist who treats cancer with radiation, may be required. Other individuals may need to be consulted as well. It is important for your urologist to keep your primary care physician up to date so that he can coordinate your care and if required by your insurance plan, make the appropriate referrals.

On a regular basis, magazine articles, books, and television shows implore those with major illnesses to seek out a second opinion. The general consensus is there is much to be gained and little to be lost, so why not seek out a second opinion? The issue certainly is more complicated than generally addressed, and deserves a review. The following chapter provides a second opinion on second opinions.
WHAT ABOUT SECOND OPINIONS?

In general, a competent physician will recommend a second opinion if there is uncertainty regarding your care. This uncertainty could involve the pathology report or debate regarding the most appropriate treatment options. Certainly if the pathology report is in question, a second opinion is mandatory! Your urologist should be able to spell out his treatment plans for you, what to expect and what alternatives may be required, depending on the seriousness of your disease. The plan may change over time as your disease improves or worsens.

You may need a second opinion if you are not doing well and your physician is unable to provide satisfactory explanations and solutions. Occasionally, your urologist may recommend a second opinion if your problem is unusual or particularly complicated. Having a physician you can trust is mandatory when dealing with cancer. Don’t let anyone pressure you into a second opinion if you feel confident in your physician’s abilities. On the other hand, if you are uncomfortable with your progress or a treatment recommendation, if you are not satisfied with the explanations given to you, don’t hesitate to seek out a second opinion. Your urologist should not feel threatened by this request as he wants you to feel comfortable with the plan of action. Only by partnering with your physician can he be most effective.

Many physicians may feel slighted when a patient requests a second opinion. Your urologist may feel somehow you don’t trust his explanations, skill, or judgment. On the other hand, when a new patient faces a difficult or unexpected diagnosis, the urologist may find the request not at all unusual. It is important you explain to your urologist why you feel a second opinion is warranted. Urologists are professionals and will graciously facilitate your request. The experienced urologist comes to realize that despite his best efforts, some patients will seek a second opinion. If a patient is particularly concerned or nervous about a proposed treatment regimen, your urologist may welcome your request. Your urologist should facilitate your second opinion by sending appropriate records and telling you whether or not it is necessary for you to bring X rays or pathology slides with you. Your primary care physician may need to be contacted for the referral if your insurance requires it.
WHY DOESN’T MY UROLOGIST WANT ME TO GO FOR A SECOND OPINION?
Often, the urologist may believe the second opinion is unnecessary and will delay treatment. He may be concerned you will not only have a second opinion, but transfer your future care to the urologist providing the second opinion. He may believe that you may get bad advice. It is possible he may feel threatened the next urologist will not agree with his work up or care of you to date.

WHERE DO I FIND A SPECIALIST FOR A SECOND OPINION?
Start by asking your primary care physician. You may be able to see another urologist in your community. Do not see another urologist in the same group as a conflict of interest may deter a different opinion. If you are considering a different course of action, such as radiation or chemotherapy, a referral to the appropriate specialist should be made.

Many times your urologist will be highly supportive and suggest a second opinion. He will offer his recommendations and facilitate your visit to the appropriate physician. If there is an issue regarding the care given at your local hospital, you may wish a referral to a “tertiary” or teaching hospital. In most areas, a referral for this reason is unnecessary, as excellent care is obtainable in the community hospital.
CHAPTER FOUR BASIC INFORMATION ON ACTOS BLADDER CANCER
Cancer unfortunately is a common disease affecting almost all animals. People are equally susceptible; approximately one in three will be afflicted at some time in their life. In this chapter, we will review basic information regarding the bladder, Actos Bladder Cancer, and cancer in general, including what causes it and some parameters used to determine how serious it is.
WHAT IS THE FUNCTION OF THE BLADDER?
A bladder stores urine and expels it at a convenient time. The bladder is a very useful organ, (tissues working together to accomplish a function), but an individual can live a normal life without one, if required, by surgical creation of a substitute.
POSTERIOR

THE BLADDER

ARE THERE DIFFERENT TYPES OF ACTOS BLADDER CANCER?
More than 90% of Actos Bladder Cancers arise from the lining bladder cells called transitional cells. Actos Bladder Cancer is almost always transitional cell cancer. These cells are also present in the urethra (the body tube which drains the bladder), as well as the renal pelvis (inner lining of the kidneys), and the ureters (the body tube draining the kidneys).

Actos Bladder Cancer can vary from the non serious, low grade superficial type (approximately 70%), to the invasive, aggressive type that can spread and prove to be fatal (approximately 30%).

5% of Actos Bladder Cancer is accounted for by squamous cell carcinoma. This cancer is usually secondary to long term inflammation or infection of the bladder. Even rarer is adenocarcinoma, which accounts for less than 2% of all Actos Bladder Cancers.

HOW COMMON IS ACTOS BLADDER CANCER?

The American Cancer Society estimates that in 2006,61,420 new cases of Actos Bladder Cancer were diagnosed in the United States with approximately 73% of those occurring in men. In the same year, this cancer caused approximately 13,060 deaths with approximately two out of three of those being in men. The disease is more common in whites than blacks. The incidence of Actos Bladder Cancer increases with age in both sexes. When Actos Bladder Cancer occurs in young people, it tends to grow slower and not be as serious. In men, it is the fourth most common cancer. However, because of the rate of recurrences and long term survival, it is the second most prevalent cancer in middle aged and elderly men. In women, it is the eighth most common cancer. The average age at diagnosis is 65. Over the past decade, there has been both an increased incidence, but also an increased rate of survival for Actos Bladder Cancer

WHAT CAUSED MY CANCER?

A mutation is a disruption in the DNA of a cell, leading to a loss of regulated cell growth. Mutations can occur spontaneously as we age. It is truly amazing that all of us don’t develop cancer as we are composed of trillions of cells dividing regularly over decades. Fortunately, our cells have repair mechanisms which can often fix damaged cells before cancer arises. In addition, the immune system can destroy cancer cells before they have a chance to grow into tumors.

Mutations and cancer can also be triggered by environmental factors. Certain chemicals have been identified to be particularly effective at inducing mutations in our DNA and subsequent cancer. These chemicals are called carcinogens. Smoking is the most common culprit! Cigarette smoking has a strong link with Actos Bladder Cancer. Studies have shown approximately 50% of Actos Bladder Cancer is secondary to tobacco smoke. Smoking releases dozens of carcinogens into the lungs and then into the blood stream. Many of these carcinogens are excreted by the kidneys. After years of being exposed to this toxic soup, a smoker’s bladder has a much greater chance of developing Actos Bladder Cancer, two to three times, and in heavy smokers up to five times the rate compared to those people who have never smoked. The risk clearly correlates with the number of years the individual has smoked and the number of cigarettes smoked per year. Fortunately, after you stop smoking, your risk gradually decreases. Once you develop Actos Bladder Cancer, it is mandatory to stop smoking. It is now known failure to stop smoking leads to a much worse outcome compared to those with Actos Bladder Cancer that stop smoking.
IT IS TOO DIFFICULT TO QUIT SMOKING; IS THERE ANY SURE FIRE WAY TO QUIT?
Tobacco smoke contains nicotine, an extremely addictive chemical. Men overall find it easier to quit smoking than women. When facing the prospects of losing your bladder to cancer or possibly your life, most individuals will become convinced and many simply stop smoking “cold turkey.” Unfortunately, many choose not to quit until their cancer repeatedly recurs or becomes invasive, needlessly placing their health at risk. For those who need assistance in quitting, nicotine patches, gum, and lozenges are all available over the counter. These products allow the smoker to quit without experiencing the discomfort of withdrawal from nicotine. Many smokers also find hypnosis or support groups useful. In addition, prescription medication is available.

ARE THERE ANY OTHER KNOWN CAUSES?

Occupational exposure may account for up to 20% of Actos Bladder Cancers. Those exposed to aniline dyes (used to color fabrics), aldehydes (used in chemical dyes and in the rubber and textile industries) and those using organic chemicals (used in a wide range of occupations) are all at increased risk. Individuals previously treated with radiation to the pelvis or having received cyclophosphamide (a type of chemotherapy) are at markedly increased risk for developing Actos Bladder Cancer. If your well water is high in arsenic, your risk may also be increased. Studies have also correlated obesity and a high fat diet, especially with increased cholesterol, as a possible contributing factor.

Surprisingly, the answer may be yes. In a recent study, the relationship of diet to cancer was analyzed in a group of47,000 health professionals. In the case of Actos Bladder Cancer, those who drank the most fluid (greater than 10 cups/day) had half the risk as those who drank the least (less than 5 cups/day). The type of nonalcoholic beverage was less important than the total amount.

Although there have been clusters of Actos Bladder Cancer reported, most researchers believe these may be secondary to risk factors such as smoking and exposure to carcinogens. At this time, there is no convincing evidence Actos Bladder Cancer risk is hereditary. If an environmental factor caused your cancer and your children are exposed as well, their risk of cancer may be increased.

The basic building block of the body is the cell. Cells are specialized to perform a particular function. Skin cells are distinctly different from liver cells which are different from bladder cells. An organ is composed of various cells working in unison to carry out a body function. Cells eventually get old and die. New cells are created by cell division. When cells are behaving normally, they only generate enough new cells to replace the old dying ones. Occasionally, cell growth becomes unchecked. As the cells continue to divide, a tumor (abnormal growth of cells) may form. Such tumors may be benign (no ability to spread beyond their organ of origin) or cancerous (a malignant tumor with the ability to spread beyond their organ of origin and cause harm and possibly death).

Cell growth is closely regulated by genes which are composed of DNA located in the command center of the cell, the nucleus. When the genes become defective, cell growth can become unregulated, and tumors can develop. Oncogenes, also called cancer genes, can be activated, resulting in uncontrolled cell growth. Other genes which help prevent abnormal cell growth called tumor suppressor genes may be inactivated. Genes can be activated which enhance the tumor cell’s ability to spread throughout the body. The body’s immune system is a critical safeguard against the formation of cancerous tumors, often destroying the abnormal cells before they have a chance to grow and divide.

HOW DOES CANCER SPREAD?

Cancer cells can spread throughout the body. They can spread through the lymphatic system, composed of lymph channels and lymph nodes, or distantly to other organs or the skeleton via the blood stream (hematogenous spread). In the case of Actos Bladder Cancer, the cells can also spread by being carried in the urine and implanting in other locations in the urinary tract.

HOW CAN I TELL IF MY ACTOS BLADDER CANCER IS LIKELY TO SPREAD?

Larger tumors are more likely to spread than smaller tumors. Another critical concern is the grade of the tumor. Normal cells are specialized, differentiated to perform specific function, and have a typical structural arrangement with surrounding cells. As cancers worsen, the cells become less specialized, less differentiated, and lose their normal structural arrangement, resulting in a higher pathologic grade.
In the case of Actos Bladder Cancer, pathologists classify them into 3 grades based on a number of criteria:

Grade 1: low grade, well differentiated Grade 2: intermediate grade, moderately differentiated Grade 3: high grade, poorly differentiated The higher grade tumors have a greater propensity to metastasize- spread throughout the body.
For Actos Bladder Cancer, another key indicator for likelihood to spread is the depth of penetration into the bladder wall. The bladder wall is composed of an inner lining called the urothelium (made up of transitional cells) which rests on a membrane layer called the basement membrane, below which is the connective tissue layer (support tissues) called the lamina propria. Within the lamina propria lies a small amount of muscle called the muscularis mucosa. Deep to the lamina propria is the deep muscle of the bladder arranged in three layers. This layer is called the muscularis propria. Tumors located in the inside, superficial layers of the bladder wall are unlikely to spread. Tumors that grow into the deeper layers (down into the muscle of the bladder wall) are much more likely to spread. Furthermore, there is a definite link between the grade of the tumor and its likelihood of invasion. Low grade tumors are almost always noninvasive, while high grade tumors are usually invasive. In general, papillary tumors, which are delicate and frond like in appearance are usually low grade and superficial. This is to be contrasted to sessile tumors which appear solid, are often high grade and invasive. Depth of invasion is critical in establishing prognosis. The tumor which invades into the lamina propria is a far more serious tumor than the superficial tumor which demonstrates no invasion. It has a much higher propensity to progress to the muscle invasive tumor, a much more dangerous cancer, with a high risk for spreading beyond the bladder. For further information see Chapter 6.

HOW IS THE GRADE OF CANCER DETERMINED?

The pathologist studies the prepared slides and makes a determination of the grade of cancer. There are a number of criterions that are used: degree of cellularity, nuclear crowding, loss of polarity and differentiation, nuclear pleomorphism, chromatin pattern and mitotic activity. In layman’s terms, the pathologist looks at the size, shape and relationship of the cancer cells. The nucleus is often abnormal since it contains damaged or mutated DNA. Cancer cells look different than normal cells. The greater the difference from normal, the higher the grade will be. These parameters are utilized to reduce the subjective nature of pathology. In the end, the pathologist assigns a grade. Since grading is actually a continuum, many pathologists find that by adding to the grading scale, they can more accurately grade what they are seeing:
Grade 1, Grade 1 lA, Grade 2, Grade 2 ‘/2, Grade 3.

CHAPTER FIVE INITIAL EVALUATION
The medical history of those with bladder cancer varies. For many patients, the first clue is blood in the urine, while in others, it may be an alteration in urination. Sometimes a tumor is found inadvertently on an X ray or ultrasound exam. In all cases, an initial assessment is implemented by the urologist. In this chapter, we will review the presenting findings of those with bladder cancer and how they are initially “worked up.”
WHAT IS THE DIFFERENCE BETWEEN A SIGN AND
SYMPTOM?
A sign is a physical finding from an underlying disease or disorder which can be noted by the individual or the physician. A symptom is something the individual feels or experiences from a disease. A clinical sign is a physical finding, while a symptom is something the individual experiences.
I PASSED SOME BLOOD IN MY URINE SEVERAL WEEKS AGO, THERE WASN’T ANY PAIN AND IT HASN’T OCCURRED AGAIN, IS THIS SOMETHING I NEED TO BE CONCERNED ABOUT?
Absolutely! Approximately three quarters of individuals with bladder cancer initially present with blood in their urine. The blood may be visible to the naked eye (gross hematuria), or seen with a microscope only (microscopic hematuria). In the case of gross hematuria secondary to bladder cancer, it is often total (throughout the entire stream) and may be intermittent. Generally, there is no pain associated with it. I have seen many patients over the years who had gross hematuria months earlier who falsely assumed their condition was not serious since the bleeding stopped and there was no pain, only to come in later with recurrent bleeding, their tumors needlessly more advanced. When an individual experiences gross hematuria, a work up is a must! Gross hematuria at times can become quite severe to the point blood clots can restrict the flow of urine. What could have been an elective assessment then becomes a mad dash to the emergency room for catheterization (passing a tube into the bladder) and irrigation or an emergency procedure. Of course, there are other causes for gross hematuria, such as urinary infections, kidney stones or tumors in the kidney, all of which require assessment.
MY PHYSICIAN FOUND A SMALL AMOUNT OF BLOOD ON A URINE DIPSTICK DURING ROUTINE EXAM, IS THERE ANY NEED TO FOLLOW THIS?
If a urine dipstick is positive for blood, it is recommended to check the urine under a microscope. The urine is first spun down to separate out the sediment and is then examined under the high power lens. If there are more than 3 red blood cells per high power field it is felt to be significant. If there are no other reasons for the presence of blood such as a urinary infection, the urine should be rechecked. If there is a persistent presence of significant microscopic hematuria, an assessment is recommended. When there is a large amount of microscopic hematuria, especially in older individuals with risk factors for bladder cancer, there is no need to repeat the urinalysis as a workup should be done.
IS ASYMPTOMATIC MICROSCOPIC HEMATURIA ALWAYS A SIGN OF SOMETHING SERIOUS?
A small amount of microscopic hematuria in an individual without symptoms (asymptomatic microscopic hematuria) can be found in many healthy individuals. It has been estimated that up to 10% of the population has asymptomatic microscopic hematuria. In brief, the older you are (generally over the age of 40), the more risk factors you have (smoking, occupational exposure), and the more red blood cells present, the more likely serious pathology (disease of the urinary tract including bladder cancer) will be found. If you have persistent microscopic hematuria without a known cause, a urologic assessment is recommended.
WHAT IS THE WORK UP FOR HEMATURIA?
When assessment for hematuria is required, the entire urinary tract is evaluated. This is accomplished via imaging studies (X ray or ultrasound), cystoscopy (visual inspection of the bladder), and possibly cytology (urine test for cancer cells). There are multiple causes for blood in the urine, including the possibility of kidney disease, kidney, ureteral or bladder stones, infection, or enlargement of the prostate.

THE URINARY TRACT

I HAVE BEEN EXPERIENCING BURNING WHEN I URINATE, BUT MY PRIMARY CARE PHYSICIAN DIDN’T FIND AN INFECTION, DO I REALLY NEED TO BE REFERRED TO A UROLOGIST?
Approximately twenty percent of patients with bladder cancer will complain of irritative voiding symptoms. These symptoms include urinary urgency (a need to rush to the bathroom), burning and urinary frequency. These same symptoms are present in other urologic conditions such as infection, bladder instability and prostatic enlargement in men. These symptoms are most commonly associated with a diffuse superficial form of transitional cell cancer of the bladder called CIS (carcinoma in situ). Unfortunately for some,
their diagnosis may be delayed since these symptoms are present in so many other diseases.
It is important to be assessed for persistent irritative symptoms!
MY UROLOGIST HAS RECOMMENDED A CYSTOSCOPY. IS THIS REALLY NECESSARY?
Cystoscopy (examination of the bladder) is usually the first step in making the diagnosis of bladder cancer. Given the signs and symptoms suggesting bladder cancer, or an X ray or ultrasound revealing a possible bladder tumor, cystoscopy is a must. Cystoscopy can be accomplished with either a flexible cystoscope or a rigid scope. The flexible cystoscope is composed of small optical fibers encased by a plastic sheath. A rigid scope has glass lenses within a metal sheath. Both cystoscopes are passed directly through the urethra into the bladder to visualize the inside surface. Cystoscopy can be accomplished in both the urologist’s office or as an outpatient at a hospital or surgicenter.
MY UROLOGIST SAYS HE CAN DO FLEXIBLE CYSTOSCOPY RIGHT IN HIS OFFICE. WILL I HAVE TERRIBLE PAIN DURING THE EXAM?
The flexible cystoscope is easier and less painful to pass, especially for males whose urethra is longer and more tortuous than in females. Flexible cystoscopy is readily accomplished in the doctor’s office. A lubricant is applied to the scope to ease passage. Local anesthesia can be squirted into the urethra prior to passing the scope. Discomfort from the cystoscope is usually well tolerated and short in duration. The discomfort usually lasts a few seconds as the scope is passed through the prostate. At that time, you may feel a pressure sensation. In females, passage of the scope is quick and relatively painless.
During the exam, your bladder will be filled with sterile water to allow complete visualization of all the surfaces. You may feel like you have to urinate. During flexible cystoscopy, small biopsies can be obtained. Any bleeding from the biopsy site is readily controlled. The biopsy and cauterization will cause pain for a few seconds. A mild oral sedative can be taken prior to an exam, but is generally not necessary. An entire examination may take only a few minutes. If biopsies are done, the exam will be a little longer. Flexible cystoscopy is very convenient. You can drive yourself to and from the office. After the exam, you can generally go right back to work. If a tumor is found that is too large to treat with a flexible cystoscope, you will be scheduled for an additional procedure at a hospital or surgicenter.
MY UROLOGIST HAS SCHEDULED ME FOR RIGID CYSTOSCOPY AT THE SURGICENTER, WHAT CAN I EXPECT?
The rigid cystoscope, although easy to pass in a female is difficult to pass without sedation in a male. The rigid cystoscope allows for generous biopsy specimens and removal of small tumors. Cystoscopy therefore can provide for both diagnosis and treatment at the same time. If a large cancer is found, removal with a resectoscope can be used to remove it at the same time. If multiple biopsies or resection of a cancer is done, spinal or general anesthesia may be required. Since rigid cystoscopy generally causes more discomfort than flexible cystoscopy and requires more anesthetic, you can expect to be out of work at least one day. In addition, someone will need to drive you home from the surgicenter or hospital.
HOW DOES THE UROLOGIST DECIDE ON WHETHER TO DO FLEXIBLE OR RIGID CYSTOSCOPY?
If you are being initially screened for asymptomatic microscopic hematuria, a urologist will often choose flexible cystoscopy as the first step. He is not certain whether or not you have a bladder cancer or other condition causing the hematuria. Flexible cystoscopy will provide that answer in a less time consuming, less painful and more cost effective way than rigid cystoscopy. On the other hand, if there is a high likelihood a tumor is present, it makes sense to do rigid cystoscopy and if required, resection all at one setting. If you are experiencing gross hematuria, flexible cystoscopy does not provide adequate visualization, and rigid cystoscopy is warranted. Many urologists use both types of cystoscopes, but some do not have the flexible cystoscope in their office.
MY UROLOGIST SAYS I CAN WATCH THE ENTIRE PROCEDURE ON A VIDEO SCREEN. I’M A LITTLE SQUEAMISH. SHOULD I WATCH?
The cystoscope may be attached to a camera so images appear on a video screen. This technology will allow your urologist to actually show you the findings during the examination. I have found many patients are at first hesitant to “view their insides,” but later thank me afterwards for having the opportunity. They often view the images with fascination and curiosity.
DO I NEED TO DO ANYTHING SPECIAL AFTER CYSTOSCOPY?
After cystoscopy, you should drink plenty of water, especially if there is some bleeding present. Mild discomfort generally lasts approximately 24 hours. It is not unusual to have some bleeding after cystoscopy, which is often the case if biopsies have been done. If you have had biopsies or a tumor has been resected, your urologist should give you specific instructions on what to avoid. Generally, it is best not to partake in heavy exercise or exertion. Avoid getting constipated as straining can start bleeding. You should call your urologist if you have persistent or severe pain afterwards, heavy bleeding (dark bloody urine or clots), persistent bleeding lasting more than a few days, inability to urinate, or a fever (temperature greater than 100 degrees Fahrenheit).
CAN CYTOLOGY BE USED INSTEAD OF CYSTOSCOPY TO RULE OUT BLADDER CANCER?
Urinary cytology is the examination of urine using special stains to look for cancer cells. These cells would have been those that have broken off (exfoliated) from the lining of the urinary tract. Voided urine is sent for analysis. First voided morning urine should not be used as there is a higher rate of cellular degeneration. To enhance the yield of cells, the bladder can be barbotaged (flushed). Cytology is most useful for high grade or aggressive tumors and for those with carcinoma in situ (CIS). In low to intermediate grade tumors, cytology may not be positive because these tumors may not exfoliate cells into the urine. In addition, if low grade tumor cells are exfoliated, they may appear to the pathologist to be identical to normal bladder cells. Due to the limitations of sensitivity of cytology, it is not a very good screening test, but proves to be valuable in following some individuals who have already been diagnosed and treated for bladder cancer.
Because a positive cytology is very specific for cancer, it is highly predictive of transitional cell cancer even if no tumor is visible during cystoscopy. Additional information can be obtained with urine cytology. The DNA content and measurement of the amount of abnormal DNA can be determined. In general, as the amount of abnormal DNA is increased, the prognosis is worsened.
ARE THERE ANY OTHER URINE TESTS THAT ARE HELPFUL IN MAKING THE DIAGNOSIS?
There has been continued research and a subsequent array of urine tests to screen for bladder cancer. Some of these newer tests include:
Bladder Tumor Antigen (BTA): measures basement membrane protein antigen released into the urine, a protein from the bladder wall.
NMP22: measures nuclear matrix protein 22
Aura Teck FDP: measures fibrin, fibrinogen degradation
products
Telomerase: measures the enzyme used to preserve telomeres (the ends of chromosomes required to continue cell division) Hyaluronic Acid, Hyaluronidase: substances which have a role in blood vessel growth in bladder tumors and tumor progression. Research goes on and newer tests may prove to be both more sensitive (positive if cancer is present) and more specific (not positive for other reasons). At this time, none of the urine tests are sensitive enough to take the place of cystoscopy in the initial evaluation of an individual suspected to have bladder cancer. In general, cytology as an adjunct to cystoscopy is more helpful than any of the urine bladder cancer tests to date.
AS PART OF MY INITIAL WORK UP, MY PHYSICIAN HAS ORDERED A CAT SCAN. WHAT’S THE PURPOSE AND ARE THERE ANY ALTERNATIVES?
When an individual has gross hematuria or persistent microscopic hematuria, a complete assessment of the urinary tract is required. Although cystoscopy is the test of choice for examination of the bladder, imaging studies are required to make sure there is no disease in the upper tracts (kidneys and ureters). Bleeding can be caused from many different disorders including transitional cell carcinoma of the upper tracts, kidney or ureteral stones, or renal cell carcinoma (cancer of the parenchyma or fleshy part of the kidneys). Your urologist has a number of options to choose from. There are advantages and disadvantages of each.
Intravenous pyelogram (IVP) is accomplished by injecting a contrast agent into your vein and then obtaining X ray images. The contrast is excreted by your kidneys, subsequently filling the lumen of the kidneys, ureters and the bladder. The contrast allows one to see subtle filling defects within chambers of the urinary tract, possibly representing tumor, stone or blood clot. Tumors of the fleshy part of the kidneys can also be seen. The study also allows for an assessment of renal function. It is a sensitive test for renal obstruction, which can occur because of cancer. Disadvantages of the study include the possibility of an IV contrast agent allergy, which occasionally may be serious.
You will be asked whether you have a sea food allergy, a known allergy to iodine or to IV contrast. If this is the case, you may need to be premedicated prior to the exam to avoid a reaction. Although the study is quite useful at visualizing the upper tracts, it is not very good at picking up subtle tumors on the bladder surface. If your kidneys do not function well (you have renal insufficiency), the contrast may cause harm to your kidneys and the imaging will not be as good. For pregnant women, any X ray exam could be potentially damaging to the fetus and therefore, will not be performed.
Ultrasonography can check for a kidney tumor, stone, or obstruction. Bladders filled with urine can be scanned. There is no contrast or X rays involved, and therefore the study can be accomplished in those with renal disease, contrast allergies or for women who are pregnant. Although larger tumors of the bladder are often visible, it is not a good study to rule out urothelial cancer (transitional cell cancer of the urinary tract lining) since smaller tumors or flat tumors in the lining are not visible. Also, other conditions such as enlarged folds in the bladder or enlarged prostates can be confused with bladder tumors. Ultrasound exams are generally fast, painless, and relatively inexpensive. An ultrasound combined with cystoscopy plus cytology (to rule out cancer cells) is a reasonable assessment for those with a low likelihood of having upper tract disease.
CT Scan or CAT (computerized axial tomography) provides a computerized cross sectional visualization of the abdomen and pelvis. X ray images are synthesized into exquisitely detailed images. The CT scan can be done with or without IV contrast, and therefore has the same limitations as IVP in those with allergies to contrast or renal insufficiency. These studies are excellent for finding renal cell cancers and stones within the kidneys and ureter, but not very good at delineating cancers of the lining. CT scan is often an important part of staging bladder cancer, determining whether the cancer has spread.
Magnetic Resonance Imaging (MRI) is a technology which uses strong magnets to provide detailed images of your internal organs. Like ultrasound, this study has no known harmful effects on the body. It does not require contrast injection like CT scan and can be done safely in patients with renal insufficiency. It is not generally used for initial screening. Many individuals find the test uncomfortable due to a loud noise heard throughout the test, in addition to the close quarters the machine requires, leading to feelings of claustrophobia. A mild sedative may be required if the test is necessary and the individual experiences these uncomfortable feelings.
Retrograde Pyelography is a contrast study of the ureters and renal collecting system done during rigid cystoscopy. The urologist injects contrast up the ureters through their respective openings in the bladder. X rays can be done during the injection and captured on

Ref: Bladder Cancer A Resource Guide for Patients and Their Families
By
Gary N. Dunetz M.D., FACS