Dr. Nagourney's Blog

A Stage IV Bladder Cancer Meets Its (Unexpected) Match

By Robert A. Nagourney, MD

I am often asked to see the family members of current and former patients, as one good outcome can beget another.

A recent clinic had 3 different family members in a single afternoon, all for different problems, diagnosed at different times.

One of my former patients with widely metastatic non-small cell lung cancer lived a miraculous 8 years, during which time I had the opportunity to meet and care for several of her friends and family members. The most recent of which proved to be particularly challenging.

This 55-year old patient complained of poor appetite followed by weight loss, sleep disturbance and abdominal pain. Her brother-in-law (my former patient’s son) asked for my input. “Doc, I am sure she has cancer” he said.

Diagnosis:  Stage IV Bladder Cancer

When I met the patient it was evident that she had kidney failure, the late result of a childhood injury that had caused a bladder obstruction.

I reassured the brother-in-law and explained that we could manage the problem with a fairly simple procedure. My reassurances proved premature however, when the urologist’s biopsy revealed a high grade and extremely advanced bladder cancer that had extended beyond the bladder to the surrounding organs and lymph nodes  

Coincidentally, the most widely used treatment for this disease, Cisplatin & Gemcitabine, was originally reported for bladder by our group in 1997 at a research symposium in Washington DC, 10 years before it became the treatment of choice. As it was now considered the “gold” standard, it was the urologist who suggested it before he would consider going on to surgery depending upon her response.

From the tone of his voice, it was evident that he was not expecting a good outcome.

Although I did not know the urologist personally, I asked whether he would be kind enough to repeat the cystoscopy (the procedure that goes inside the bladder enabling the doctor to do a biopsy) to provide tissue for our EVA/PCD functional profiling analyses. He kindly agreed.

Stage IV Bladder Cancer Treatment Options

Despite my long and successful experience with Cisplatin & Gemcitabine, I was surprised to find that this patient’s tumor was much more sensitive to the combination of Carboplatin &Taxol, a combination that is sometimes used in recurrent disease but generally not in the first-line setting. When I reported my findings, I recall the urologist was somewhat taken aback by my willingness to depart from the community standard.

Convinced of the finding I personally assumed the patient’s care and proceeded with Carboplatin & Taxol, just as the laboratory suggested. After 4 cycles the improvement was dramatic and the PET/CT was returned to normal. In preparation for surgery the urologist ordered a pre-operative CT scan.

A new finding, not detected on the recent PET/CT, showed a mass on the kidney. Her bladder tumor appeared to have escaped control and metastasized to the kidney. Had we missed something?  To answer the question, a biopsy of the kidney would be required before the planned aggressive surgery could possibly be contemplated.

The biopsy was obtained, but instead of bladder cancer, it revealed nothing more than a benign process known as an Oncocytoma, completely unrelated to the bladder tumor. It hadn’t shown up on the PET-CT because it is so metabolically inactive and doesn’t light up.

Reassured, the surgeon proceeded to bladder removal and lymph node dissection. We awaited the arrival of the tissue sample as we felt there would likely to be more work to do.

As the afternoon wore on, the pathologist still hadn’t sent the tissue. I became concerned. Was this patient, of all of my many patients, going to be one for whom the usually smooth coordination with Pathology would fail?

No. The pathologist kindly called and explained that they could not identify any viable tumor; none. Knowing this to be only a frozen section, I awaited the final pathology report.

And then it arrived: Pathological complete remission. With just 4 cycles of a combination that she would otherwise not have received the patient was now quite likely to be cured.

As I considered my concern when the kidney mass was found, I realized that this was a vindication of our approach and our conviction to use the best option for this patient despite the misgivings of others.

Bladder Cancer Ideal For Functional Profiling

Bladder cancer is a common malignancy with over 72,000 new cases and 15,000 deaths in the US each year from this diagnosis. How many of these patients might be cured if they received the right treatment the first time?

How often does someone referred for Cisplatin & Gemcitabine (like this Stage IV bladder cancer patient) or CMV or MVAC or one the other drug combinations get the wrong treatment for them?

Bladder cancer is an ideal disease for our approach as it is drug responsive, a good candidate for combined modality of surgery plus chemotherapy and potentially curable.

I contacted the patient’s brother-in-law and told him that it seemed that more than just the chemotherapy had led to this good outcome. There was the goodwill of a family, the kind support they had provided us over the years, the excellent outcome of his mother and the surprisingly good outcome of several other family members.

It is said that cancer is not a disease of the individual, but a disease of the family, as it takes such a toll upon every family member.

But it is equally true that a good outcome in cancer is an uplifting renewal for every member of the family. I couldn’t be happier for this patient’s good outcome and feel a sense of particular pride that this family was spared the hardship that so aggressive a cancer might otherwise have wrought.

As always, I appreciate your thoughts and comments. 

 

Dr. Robert Nagourney, has been internationally recognized as a pioneer in cancer research and personalized cancer treatment for over 20 years.  He is a TEDX SPEAKER, author of the book OUTLIVING CANCER, a practicing oncologist and triple board certified in Internal Medicine, Medical Oncology and Hematology helping cancer patients from around the world at his Nagourney Cancer Institute in Long Beach, California.  For more info go to NAGOURNEYCANCERINSTITUTE.COM