Bladder Cancer to Smooth SailingLike a lot of guys, Mark Corgiat doesn’t run to the doctor at every ache and twinge. So when he noticed blood in his urine, Mark assumed it was a bladder infection that would pass.
“There was no pain, I wasn’t running a temperature — it was no big deal,” said Mark, an executive recruiter from Delafield. Even when he did visit his primary care physician to get a prescription for smoking cessation medication, he didn’t mention what he was experiencing until he was almost out the door. “My doctor took one look at me and said, ‘men don’t normally urinate blood,’” Mark said. “He walked me down the hall to radiology. And that’s where it all started.”
Mark had bladder cancer. Blood in the urine is the most common symptom of bladder cancer. And as a 59-year-old white man who smoked, Mark fit the profile of many who are affected by the disease. The National Cancer Institute at the National Institutes of Health estimates that there were more than 73,000 new cases of bladder cancer in 2012 (the ratio of men to women affected is 3 to 1). In most of those instances, the cancer was confined to the surface of the inner lining of the bladder. In others, the tumors had infiltrated the bladder wall. Both are treated with minimally invasive procedures to remove the cancer cells from the bladder wall and apply a chemotherapy drug directly to the site to help prevent recurrence of the disease. But in Mark’s case, the tumor had invaded the muscle layer of the bladder, putting him at greater risk of the cancer spreading to other organs.
Options for Invasive Bladder CancerCharacterizing Mark’s condition as “high grade and invasive,” Mark’s urologist referred him to Froedtert & The Medical College of Wisconsin for a second opinion. Froedtert & The Medical College of Wisconsin’s Prostate and Urologic Cancer Program is a leader in the state, treating bladder and ureteral cancers, and cancers of the prostate, kidneys, testes and penis.
At Froedtert & The Medical College, he was seen by Peter Langenstroer, MS, MD, Medical College of Wisconsin urologic oncologist, and Kathryn Bylow, MD, Medical College of Wisconsin medical oncologist, who confirmed his diagnosis. Mark’s treatment options were a course of chemotherapy and radiation, or a cystectomy (the surgical removal of the bladder), followed by a urinary diversion procedure to fashion a new system for storing and eliminating urine. “The gold standard in the United States remains removal of the bladder,” Dr. Langenstroer said. “Patients are presented with both options, but generally, chemo and radiation is therapy for patients who either don’t want an operation, or who are not medically well enough to undergo surgery, often older adults.”
For those who cannot or will not tolerate bladder removal surgery, notes Colleen Lawton, MD, FACR, Medical College of Wisconsin radiation oncologist, the first step is TURBT (transurethral resection of the bladder tumor). “The surgeon will remove the cancer,” she explained, “then, after a healing period of several weeks, patients are treated with chemotherapy and radiation therapy five days a week for about five weeks. We usually pause at that point, and the surgeon checks to be sure there’s no evidence of recurrence. If there isn’t, we finish with a seven-and-a-half week half course of radiation, usually administered with chemotherapy.”
Urine Management OptionsMark opted for surgery. He then had to decide how he wanted the urinary diversion aspect of his care addressed. One option would have Mark using an external bag to collect urine and another would have created an internal pouch that is drained with a catheter. The third option was a neobladder, which allows near-normal function. Using a small piece of the patient’s small intestine, a storage reservoir – or neobladder – is created, allowing patients to urinate normally.
“I had never heard of the neobladder procedure,” Mark said, “but Dr. Langenstroer thought I was a good candidate. Deciding to go for it wasn’t hard, because I enjoy a fairly active lifestyle and wanted to maintain that as best as possible.” Mark is an avid boater and loves to be out on the water.
Pre-Surgical Chemotherapy ImportantMark’s pre-surgical work-up included CT scans of the chest, abdomen and pelvis, followed by a course of chemotherapy under the direction of Dr. Bylow. “Studies show that administering chemotherapy before surgery reduces the chance of the bladder cancer returning,” Dr. Bylow said. It is now the national standard in bladder cancer treatment and is followed by physicians in the Prostate and Urologic Cancer Program.
“At a recent American Society of Clinical Oncology conference I attended, a presentation revealed that not all hospitals are following this standard of providing chemotherapy before surgery,” Dr. Bylow said.
Of his own chemotherapy experience, Mark said, “I had three rounds, each one lasting about 28 days. At first, I didn’t feel debilitated. But by the third round, there were mornings when I didn’t have the strength to pick up a cup of coffee.”
Robotic Cystectomy and Neobladder ProcedureWhen it came time to remove Mark’s bladder, Dr. Langenstroer sought the additional expertise of Kenneth Jacobsohn, MD, Medical College of Wisconsin urologic oncologist, an expert in employing robotic technology in the operating room.
“We have vast experience in robotic cystectomy,” Dr. Jacobsohn said. “The robotic approach, compared to an open approach, usually results in fewer complications, less pain, faster recovery, and earlier return to normal activities without compromising the cancer control.” Often, a single surgeon performs the cystectomy and reconstruction surgeries, but Dr. Langenstroer believes a team approach allows physicians to work at their optimal best. “These operations can easily run six to eight hours,” he said. “In those first hours, the cancer surgeons are there to maximize the cancer outcome. Then a fresh pair of hands arrives with the reconstruction surgeon, who is there to maximize the outcome of the diversion part of the operation. We’ve had that model here for more than 10 years, and we believe that when doing extended operations that require multidisciplinary expertise, assembling a team offers the patient the finest level of care.”
The reconstruction component of Mark’s surgery was performed by Michael Guralnick, MD, FRCSC, Medical College of Wisconsin urologist. “Generally, people who have neobladder reconstruction have to be in pretty good shape,” Dr. Guralnick said. “They need to have good urinary control before surgery and no incontinence. Additionally, their cancer status has to be such that the cancer is pretty well confined to the bladder and not advanced to the urethra, which would require removal of the urethra.”
Neobladder surgery became more common beginning in the 1990s and the Prostate and Urologic Cancer Program at Froedtert & The Medical College of Wisconsin performs the procedure often. “We utilize a small piece of the patient’s small intestine and fashion it into a reservoir, almost spherical in shape, that becomes our storage reservoir or neobladder,” Dr. Guralnick explained. “Then we attach the ureters, which are the tubes that drain the kidneys to the bladder, to this reservoir. The reservoir is hooked back up to the urethra, which takes the urine out of the penis.”
Only Bladder Cancer Support Group in WisconsinA key component of Mark’s experience was the bladder cancer support group, which he began attending before he had surgery. “Individuals who are newly diagnosed can be anxious,” says the group’s facilitator, Heidi Stark, BSN, RN, nurse coordinator in the Prostate and Urologic Cancer Program. “It helps them to see people who are maintaining their daily routines with bladder cancer. They know there’s hope.”
The bladder cancer group is the only group of its type in Wisconsin, and meets monthly in the Froedtert & The Medical College of Wisconsin Clinical Cancer Center. “It’s a time to see how everyone is doing, share a few laughs, and get educated,” Mark said. “Doctors to dietitians come in and make presentations to the group.” Mark and his wife, Jeannie, still attend regularly. “Sometimes, Heidi will ask if I can talk to someone new in the group, and I do,” Mark said. “And if that person has a spouse, I’ll ask if they’d like to talk to my wife, because there are things our caregivers go through that are just as huge as what we go through.”
Back to Old SelfMark had the operation in March 2011 and it was a success, but he admits that it took some time before he was really feeling like his old self. Now, as Mark works in the yard, spends time with his two grown children or goes boating, he is grateful that his cancer was caught in time. He is also appreciative of the care he received at Froedtert & The Medical College of Wisconsin.
“The staff was incredible,” Mark said. “The kindness, the consideration was unsurpassed. They are so tuned in to your needs. I had never been in that position before and didn’t know what to expect. All I can say is the people at Froedtert are extraordinary.”
Author: Dustin Kehrmeyer
Date: Feb. 7, 2013