Follow-up from second TURBT

A quick update on my cancer:  Last Thursday, I had a another TURBT procedure at GW to remove the bladder muscle that was located under the tumor that was removed on December 1.  In addition, the doctor also removed a number of smaller nodules of less invasive cancer that were scattered elsewhere in the bladder.  The tissue was sent to the pathologist for testing.  Today, Jennifer, Chelsea and I met with the urologist, who had the pathology results.  The pathology confirmed the earlier diagnosis of high grade invasive urothelial carcinoma.  For the scattered carcinoma in-situ, the pathology found that there was invasion into the lamina propria, but not into the bladder muscle (e.g., T1+Tis). The pathology under the tumor base found that the principal tumor had invaded into the bladder muscle (muscularis propria, or Detrusor muscle).  This was the key missing piece of information from the first procedure, and indicates that the primary cancer had deeply invaded the muscle (Stage 2b).  This means that my cancer has been definitively staged at pT2b+ T1+Tis, N0, M0.

What this means from here has yet to be determined, however.  Apparently the entire field of urology is in the middle of a sea change.  The traditional treatment for this type of muscle invasive bladder cancer is to remove the bladder, prostrate, and surrounding lymph nodes (radical cystectomy), and also have systemic chemotherapy and radiation therapy.  As recently as two years ago, this was the standard of care.  The downside of radical cystectomy is the loss of the bladder, and about a third of all patients are left impotent.  In the past 18 months, however, more than a half-dozen studies have suggested that improvements in chemotherapy suggest that radical cystectomy is unnecessary.  Instead, those studies suggest that, after the tumor has been removed, immediate (pre-adjuvant) chemotherapy and radiation, combined with careful follow-up, can be just as effective as radical cystectomy, without any of the debilitating side effects.  Because these studies are so new, however, there is some controversy, especially among long-time urologists who have been trained to cut everything out that might have cancer.  (As the chief urologist at Hopkins told me two weeks ago, "when your only tool is a hammer, everything looks like a nail.")

My urologist has acknowledged all of this recent information, and recommended that I meet with GW's oncologists and radiologists, and also seek a full-blown second opinion from the Hopkins team.  He also suggested that I consider talking to Sloan-Kettering or the Cleveland Clinic.  In response to Jennifer's questions of, if this were your bladder, what would you do?", he said that the most important thing was to select a team that will coordinate and direct my treatment.  He said that the leading cancer centers such as Hopkins, Cleveland Clinic, or Sloan-Kettering, were very good about adopting a multi-disciplinary team approach.  In what I thought was a candid admission, he tacitly acknowledged that most other places, including GW, were not that good at managing cases on a team approach.  He also said that, based upon the recent advances, the oncologist, and not the urologist, likely would be the key person directing the team. 

By all accounts, the next treatment likely will be pre-adjuvant systemic chemotherapy.  Apparently the type of chemo has been evolving as well; MVAC is now less favored than GC, and recent studies of paclitaxel with GC suggest that it can be even more effective.  When I met with GW's oncologist a couple of weeks ago (who just wrote a chapter of chemo for bladder cancer), she noted that very recent studies have suggested that some cancers can be sequenced and designer chemotherapies can be developed that best target the specific type of disease.  I'm meeting with her again tomorrow, and I'm also going to have another consult with the team at Hopkins, then we'll take it from there.  Stay tuned! 

Once again, thank you for your ongoing expressions of support, faith, and prayers.  I draw considerable strength knowing that there are so many people out there who are pulling for me.  I am grateful to all of you for your ongoing care.  I am grateful that I can count on the support of my family, friends, employer, and church, and am comforted that I don't have to bear this burden by myself.  This experience has reaffirmed the importance of strong human relationships, the power of compassion, and the inner peace that is grounded upon faith in God.