Cancer Surveillance
Millions of Americans (approximately 40%) will have cancer at some point in the life. They may notice a lump in their breast or a worrisome mole on their skin (melanoma). Perhas a swollen lymph node (lymphoma), difficulty swallowing (esophageal cancer), an unexplained fracture of a rib (myeloma) or back pain (renal cancer)
Do silver linings ever have clouds?
Sixteen months ago, I had a chemotherapy session coincidentially scheduled on my birthday. When my NP came out to the waiting room for me, she had a card and a balloon and she informed my wife and I that I was no longer scheduled for chemotheraphy, having completed the regimen. My urologist said I was officially reclassified by my physician as NED (no evidence of disease). Note that my physician did not say I was cured. How could she or any oncologist make a claim like that, when cancer (at least some types) can lurk in an undetectable area of the distal ileum, the peritoneal cavity, or other places, visible only on autopsy. After five years if I was still NED, there might be ça se fête, but 2030 was–and is–a long way off as far as cancer patients are concerned.
Yesterday, I had my semi-annual cystoscopy. As usual, the procedure was prefaced with a CT done several weeks earlier. The CT report noted “there is is asymmetric thickening of the anterior bladder wall, similar to prior exams” but concluded there was: “No suspicious genitourinary lesion. No evidence of recurrent or metastatic disease.” What would the cystoscopy reveal?
My wife and I were led to the treatment room. I was prepped as usual and then the doctor came in. We exchanged pleasantries and laughter. We have an excellent relationship with my physician and my wife and I have learned to trust her skills and especially her intuition which is equally as valuable as well.
There were no residents present this time. It was just my doctor, her NP, my wife and I in the room. She inserted the cystoscope
My urologist follows the same sequence each time. She visits the prostate gland, then enters the bladder and checks the trigone and the uretal orifices. From there she sweeps the interior of the bladder, finally coming to rest at the area where my cancer was first discovered and the tumors removed. At this point, my wife observed, may doctor’s affect became a tad more serious. Not exactly what Queen Gertrude in Hamlet might refer to it as a “nighted color,” but still . . .Up until now, the urethra, prostate, bladder neck and ureteral orifices were all unremarkable, except for a small amount of benign prostatic enlargement. At the post-op site she noted:
The bladder appeared unremarkable. Fine blood vessels noted. Evidence of previous treatment sites visible. Small area of redness at one of the previous treatment sites, that has been biopsied in the past, will continue to observe. No masses. No evidence of cancer recurrence. Bilateral ureteral orifices visualized with normal drainage.
She paused a few moments, mentioning the reddish area (upper photo, right), almost certainly representing an inflammation. It ihas generally been present to a greater or lesser degree in the past, but was thought to possibly be related to my chemotherapy treatments. But now, I am no longer receiving treatments.
Because I blog and I’m curious, I asked my doctor if she wouldn’t mind printing a random photo of my bladder and she had no objection. This actually seemed to be a teaching moment for the NP, and as it turned out there were two photos of my bladder produced, the one on the top left apparently what a normal bladder wall would look like three quarters of a century old, and then the erythematous tissue on the top right photo. And while the areas involved in the two photos appear to be huge, they likely represent a sample not much bigger than a postage stamp. The last thing that was done before the cystoscope was removed was a bladder washing. Here, the bladder is flushed with a sterile solution and then fifty or seventy five milliliters are captured in a sterile contained for cytology. The cells in the solution will also provide information. Are they normal? Are they abnormal? Are any cells cancerous?
No evidence of cancer recurrence
We could easily accept this cystoscopy report as a slam dunk. First of all, it corroborated what the CT findings were (i.e., nothing). Also, even as our urologist seemed to deliberate, she did not take a biopsy. On the other hand, she was certainly wondering “what if . . .?”
This cystoscopy was not a so-called “blue-light cystoscopy” which in some cases is more revealing that a “white-light cystoscopy.” But there was no reason to think that something was “missed” because of the instrumentation used. Then too, my wife and I know from the data that ~77% of HG Ta cancers return over a five year period. That leaves us grateful for the moment, but we keep our bucket list close by.
As I mentioned earlier, we have a great deal of confidence in our physician, as you should in yours. I know from working in clinical settings myself that not every doctor brings best practices and an outstanding bedside manner to bear. We will wait the 7-10 days for the cytology report. If the report recommends any need for immediate action, then my wife and I are confident we’ll hear from my physician.
What might she say if the bladder washing captured malignant (and most likely high grade) cancer cells? In that case, carcinoma in situ (CIS) would be the logical culprit assuming the malignant cells did not arise elsewhere, and a blue light cystoscopy could follow. It is possible for CIS to evade detection, so the washing is an extra layer of surveillance. THe bladder washing might also show cells that are not cancer, but neither are they normal. These cells might be a sentient sign of what might follow.
The cytology report came in and read as follows:
Bladder, washing:
Benign
Reactive urothelial cells.
The word “benign” pops out and a patient (and their spouse) lets out a sign of relief. But then, what are “reactive urothelial cells”?
The inner lining of the bladder is formed by urothelial cells, and individual cells are normally shedded just as epithelial (i.e. skin) cells are. So it is not surprising to see their presence on a slide.
What are reactive urothelial cells?
The bladder has many different cells in it. It has basil cells, muscle cells, connective tissue cells and urothelial cells (among other types). A urine specimen can contain red blood cells (erythrocytes), white blood cells (leukocytes), malignant urothelial cells, and urothelial cells (among other types). These urothelial cells are typically shed from the bladder lining, but in fact are present all along the urinary tract from the renal pelvis and calyces of each kidney to the prostatic urethra below the bladder (in males).
Reactive urothelial cells are technically (histologically) not normal. They frequently associated with conditions that irritate or inflame the bladder lining, as bladder infections, passing kidney stones, catheters, surgical procedures on the bladder, chemotherapy, radiation and cancer. Some urothelial cells are injured, and the injury may affect their ability to repair themselves correctly. One such example is an enlarged nucleus as we see in the photo to the right.
The practical interpretation: if a urine cytology or biopsy report says “reactive cells/changes,” it almost always means benign reactive urothelial cells (often with inflammatory cells in the background), not a specific separate “reactive cell type.” Lane Z, Epstein JI. Polypoid/ papillary cystitis: a series of 41 cases misdiagnosed as papillary urothelial neoplasia. (Am J Surg Pathol. 2008 May;32(5):758-64.)
So, at the moment, I am hopeful, knowing on the other had that life is often fleeting. To say that there is “no evidence of disease” is to admit that there are limitations to the state of medicine today, and every cancer patient finds themselves confronting the same ambivalence.
During this season in their life, they dread every x-ray, ultrascound, CT or MRI that their doctor orders. Every ache, pain, or change in their normal routine, however brief or insignificant becomes a referendum on their cancer’s return and their adrenaline and cortisol levels peak sharply. They have spent their immediate past living according to a fixed routine that their care team has provided. When I was getting chemotherapy for active cancer, I had a certain confidence in the drugs I got routinely. It was as if I was floating in shark infested waters and the chemo was shark repellant. Which on that birthday I was told that the sharks are gone and I would not receive any more repellant, I immediately became nervous, and not even the balloons they presented me could cheer me up. I was in angst of going another month without the gemcitabine and docetaxel. How can anyone possibly know that in the ocean, there are no sharks lurking about? You may not see them, but . . .How could anyone reasonably assure me that I had no cancer?
Yet, for all the credit that I gave to my care team, the gemcitabine and docetaxel, I owe much more to my God who truly sustained me, and over time that realization has settled in. Not compltely, because I’m mortal and at my advanced as I’m facing end of this life one way or another.
I’m saddened that others I know are not getting more time to spend with their loved ones, less pain and the promise or a new begining, which is in itself a challenge. My wife who has been entirely loving and devoted to me during this experience and I are trying to reconfigure our future. Do we want to travel abroad. Where do we want to be five years from now? Having cancer is a humbling experience.
I want to provide an important caveat. I am not a physician, and I cannot offer medical advice. I am a cancer patient myself and I do blog on cancer among other topics using the professional literature. As a retired educator, I have learned to make difficult concepts easy to understand. However, you should always check with your doctor before modifying, or abandoning any prescribed therapy.
