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Genitourinary Cancer Archive Questions

Below are Dr. Heather Mannuel’s answers to Genitourinary Cancer questions
received through the Ask the Expert feature.

This content is provided for informational purposes only, and is not intended
to be a substitute for individual medical advice in diagnosing or treating a
health problem. Please consult with your physician about your specific health
care concerns.

Now displaying records 1 to 15 of 18.

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Q : 1

I have been diagnosed with stage II bladder cancer and have gone through two rounds of BCG treatments and biopsies. Short of removal of my bladder, are there any other therapies or treatments to try with reasonable risks and results? I was told they were going to try BCG with Interferon but it's no longer available.

Although several other chemotherapy agents are available for instillation into the bladder after failure of BCG, they're generally ineffective once the tumor has already invaded into the muscle layer (stage II). Removal of the bladder remains the gold standard of treatment, but bladder-sparing therapy using combinations of chemotherapy and radiation are now becoming an acceptable alternative for patients who are unable to tolerate surgery or who wish to keep their bladder intact. If this sounds like an option you'd be interested in, I'd recommend consulting with a radiation oncologist who specializes in treatment of the bladder and prostate, as they'll be best able to minimize the potential side effects of therapy. Generally, chemotherapy is given once a week during this type of radiation, is at a low dose, and is well-tolerated by most patients.

Q : 2

I am taking Flomax and Avodart. Do they interact with herbal anti-depressants like St. Johns Wort?

In reviewing the literature, I didn't find any citations that suggested St. John's Wort may decrease the effectiveness of either Flomax or Avodart. However, information on exactly what steps should be taken to counteract this isn't specified as there haven't been many large studies that evaluate the effectiveness and mechanisms of herbal or "nutraceutical" supplements. I'd recommend continued careful monitoring of your PSA and urinary symptoms, and if you or your urologist notice a trend of the Flomax or Avodart becoming less successful, you could consider discontinuing the St. John's Wort and monitor how it effects your symptoms.

Q : 3

Does your department use titanocene dichloride as an anti-tumor drug? Can it be used rather than cisplatin? How does it compare to cisplatin?

At this time, titanocene dichloride and its derivatives are being used within the context of clinical trials only. From what I've been able to research, most of the investigation appears to be UK-based at this time. Although the anti-cancer properties sound promising, it will likely be some time before the drugs are directly compared to standard of care agents such as platinum compounds.

Q : 4

I am a 60-year-old male in good health. Lately I have a light to moderate pain in the lower abdomen on the right side. I did a self examination of my testicles and found that the right testicle is the same size as the left at the top and bottom, but is smaller in the center (like a peanut). Is this common? There were no lumps or bumps.

It's true that the testicles should be approximately symmetrical, but just as women can have slightly asymmetrical breasts, men can also notice slight differences in the shape or size of their testicles, and it can be a normal phenomenon. However, as you're having discomfort on the same side of your abdomen, I think it would be a good idea to see a urologist for an exam and possibly further workup to make sure there isn't anything that needs to be further addressed. And bonus points to you for doing a self-examination - getting familiar with exactly what's "normal" and baseline in your body is key to early detection of cancers and better outcomes.

Q : 5

My husband has grade 1 prostate cancer and we are doing PSA testing every three months to monitor his condition. His doctor has suggested 5 cups of green tea per day. He hates it and we were wondering if the green tea capsules are as effective. He's also tried pomegranate juice as an additional source of antioxidants.

The study of natural disease-fighting substances (nutraceuticals) is rapidly growing, but as there haven't yet been any large clinical trials designed around these agents, it's hard to provide any hard data as to their effectiveness in treating or preventing cancer. Green tea contains four principle antioxidants, the most important of which appears to be EGCG, so any green tea extract that contains this antioxidant should be as effective as drinking the tea itself. Pomegranate juice also appears to be promising, but as with the rest of the nutraceuticals, we still have a lot to learn!

Q : 6

Are there any effective treatments for metastatic, high-grade, large cell, neuroendocrine prostate cancer other than chemo? Are vaccines or targeted therapies options?

At this time, chemotherapy remains the mainstay of treatment for this form of prostatic carcinoma. However, as this is a fairly rare disease I would strongly encourage you to look for clinical trials in your area or via the NIH or NCI Web sites that address second- or third-line therapies in the event that the cancer recurs post-treatment. Phase I trials often address this kind of issue in rare cancers and may be applicable under those circumstances.

Q : 7

I am a 65-year-old man with hypertension, diabetes and prostate cancer with bone metastases with minimal symptoms. What are the treatment options? Do you ever recommend brachytherapy as part of a treatment plan for stage IV cancer?

Brachytherapy generally isn't used in patients who already have stage IV cancer, although occasionally external-beam radiation is used if the patient is having symptoms from an enlarged prostate gland that makes urination difficult. If a patient has bone metastatic disease I recommend starting hormonal therapy, as it's best to get the disease under control before symptoms such as pain and weight loss present. I also recommend starting calcium and vitamin D to help preserve bone strength. The above recommendations are our "gold standard" of care, but as always, I encourage people to check out clinical trials in their area, as they may provide beneficial therapy that isn't otherwise available.

Q : 8

I am experiencing numbness in my hands and feet from chemo therapy, will this go away?

Unfortunately it's hard to predict whether numbness (neuropathy) will subside or not. It depends on the specific types, doses and duration of chemotherapy. Additionally, any underlying or preexisting illnesses, such as diabetes, can make it harder to recuperate from symptoms. Generally most patients regain most of their sensation within several months of completion of therapy. In patients who are bothered by persistent neuropathy, I generally start with vitamin B6 and if that doesn't work I prescribe either gabapentin (Neurontin) or pregabalin (Lyrica).

Q : 9

I am changing doctors and clinics since I had a prostatectomy in March 2008. What are the appropriate follow-up steps I should be taking, and how often? What should I expect a new doctor to do during examination? PSA test only?

If you haven't required any treatment other than the prostatectomy (for example, no chemo, no radiation etc.), the best first step is to meet with a urologist. He or she will go through your medical records with you, check a PSA and most likely perform a rectal exam as well. As long as your exam and your PSA are normal, you'll most likely be scheduled for follow-up appointments only two or three times a year. These are great questions and you should go through them carefully with your new doctor to come up with a personalized plan that addresses your needs and your medical history.

Q : 10

I am a 46 year old male who doesn't smoke and I have a horseshoe kidney. I have been experiencing intervals of blood in my urine for 3 or 4 weeks. My urologist did a IVP, urinalsysis and a regular exam. He also sent my urine to pathology to check for cancer cells. All the tests have come back negative, but I still have blood in my urine from time to time. I notice it more after I ride a stationary bike or lift weights. My urine clears up quickly but it always seems to come back. What are your thoughts?

Exercise-induced hematuria (blood in the urine) has been well-documented to occur after several different types of exercise, including cycling and weight-lifting. The exact reason behind this occurrence isn't known, but generally it's considered benign, and it sounds like you've had a thorough work-up to rule out other causes or problems. You may want to see a nephrologist (specialist in kidney diseases) to rule out any rare or familial diseases that could explain the bleeding.

Q : 11

My Father-in-law has been told that he has bladder cancer and that the growth is in the inner first skin layer. He is now at the stage were he has been offered biological therapy. What is the success rate of this treatment and should it be expected to totally eradicate the growth? What are the risks involved? Should he just have his bladder removed?

From your description, it sounds as though your father-in-law is being offered treatment with BCG. Although its exact mechanism of action is unknown, BCG is believed to trigger a localized immune activation that results in production of interleukins, interferons, and other substances that may play an active role in killing cancer cells. In various studies, BGC was found to delay the progression to more advanced cancers, decrease the need for future surgery, and prolong overall survival. Because it may only delay progression of cancer and not necessarily prevent it from recurring, your father-in-law should continue to follow up closely with his physicians. He should also have regular evaluations of his urinary tract, so that any recurrences can be caught quickly.

Q : 12

My mother has been treated for bladder cancer twice. They have now found more tumors in her bladder and she is having a biopsy next week. What percentage of people with bladder cancer have recurrences like this? Her doctor told her that some patient's cancer is consistently reoccurring. At what point is a more aggressive form of treatment warranted?

Unfortunately, 40 to 80% of patients will have recurrences of their superficial bladder cancer and up to 25% may develop a more aggressive muscle-invasive disease. The next course of treatment for your mother will be influenced by the results of her upcoming biopsy. If the biopsy shows invasion into the bladder muscle, the next step to decrease risk of recurrence will likely be a cystectomy (surgical removal of the bladder). Chemotherapy and combined chemotherapy and radiation are alternative treatment methods for patients who aren't healthy enough to have surgery or who opt against having their bladders removed.

Q : 13

My 82 year old father was diagnosed with a bladder tumor in March 2008. He had a TURBT and the tumor margins were negative for any additional transitional cell carcinoma. In June 2008 and again in September, he tested negative for any malignancy. Recently, another tumor was found. He had another TURBT (path is not back yet), however his physician has indicated that this one was deeper and was different. What will his treatment options be? He has a one episode history of CHF and pulmonary HTN. His last echo was improved. He is active for an 82 year old and doesn't smoke or drink. I am concerned that the only option may be a cystectomy and I don't know if he could tolerate that.

The final pathology will be important in making definitive treatment recommendations, but if the specimen shows muscle-invasive bladder cancer the two major available options are generally surgical removal of the bladder (cystectomy) or combined chemotherapy & radiation. The latter may be a better option for your father if his other medical issues are felt to make a large operation and prolonged anesthesia too risky. Although the cure rate for patients who have been treated with chemo/radiation may be slightly less than that of patients who have had their bladder surgically removed, most people tolerate and recuperate from this therapy quite well with minimal residual side-effects. It sounds like overall your dad is quite fit and healthy, and particularly if his cardiac & pulmonary issues are under adequate control, the final decision may come down to what he feels will have the least impact on his quality of life.

Q : 14

I am 56 years old and just had a PSA with results of 3.7; two years ago it was 2.4. My doctor has suggested that I have it retested in June. Do you think I should wait that long?

Fifty-six is younger than the average age for men who develop prostate cancer, but it is still is a concern. Your risk of developing prostate cancer increases if you've had family members who were diagnosed with prostate cancer at a young age or if you're African-American, as there tends to be an increased incidence of earlier, more aggressive prostate cancer in these men. It's always important to look at the overall trend when we measure PSA levels, which is obviously tough to do when you only have two measurements at this time. As it looks like you had a fairly significant jump in PSA over two years, I'd recommend re-checking in about two months rather than six. If the level remains the same or has decreased again, it will probably be safe to monitor every six months. If it's climbed above 3.7 you should see a urologist to discuss further investigation, which might include a biopsy.

Q : 15

I have had a lump on my right testicle for a while now. The lump is on the tip of my testicle and feels like it is connected to my tube. Is this normal or something I should get checked out?

It's always advisable to get any new lumps or bumps checked out just to be safe. I'd recommend seeing a urologist for further work-up.

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