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Actos Side Effects : CAN CYTOLOGY BE USED INSTEAD OF CYSTOSCOPY TO RULE OUT BLADDER CANCER?

Urinary cytology is the examination of urine using special stains to look for cancer cells. These cells would have been those that have broken off (exfoliated) from the lining of the urinary tract. Voided urine is sent for analysis. First voided morning urine should not be used as there is a higher rate of cellular degeneration. To enhance the yield of cells, the bladder can be barbotaged (flushed). Cytology is most useful for high grade or aggressive tumors and for those with carcinoma in situ (CIS). In low to intermediate grade tumors, cytology may not be positive because these tumors may not exfoliate cells into the urine. In addition, if low grade tumor cells are exfoliated, they may appear to the pathologist to be identical to normal bladder cells. Due to the limitations of sensitivity of cytology, it is not a very good screening test, but proves to be valuable in following some individuals who have already been diagnosed and treated for bladder cancer.

Because a positive cytology is very specific for cancer, it is highly predictive of transitional cell cancer even if no tumor is visible during cystoscopy. Additional information can be obtained with urine cytology. The DNA content and measurement of the amount of abnormal DNA can be determined. In general, as the amount of abnormal DNA is increased, the prognosis is worsened.

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ARE THERE ANY OTHER URINE TESTS THAT ARE HELPFUL IN MAKING THE DIAGNOSIS?

There has been continued research and a subsequent array of urine tests to screen for bladder cancer. Some of these newer tests include:

Bladder Tumor Antigen (BTA): measures basement membrane protein antigen released into the urine, a protein from the bladder wall.

NMP22: measures nuclear matrix protein 22

Aura Teck FDP: measures fibrin, fibrinogen degradation

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Telomerase: measures the enzyme used to preserve telomeres (the ends of chromosomes required to continue cell division) Hyaluronic Acid, Hyaluronidase: substances which have a role in blood vessel growth in bladder tumors and tumor progression. ^[1] Research goes on and newer tests may prove to be both more sensitive (positive if cancer is present) and more specific (not positive for other reasons). At this time, none of the urine tests are sensitive enough to take the place of cystoscopy in the initial evaluation of an individual suspected to have bladder cancer. In general, cytology as an adjunct to cystoscopy is more helpful than any of the urine bladder cancer tests to date.

AS PART OF MY INITIAL WORK UP, MY PHYSICIAN HAS ORDERED A CAT SCAN. WHAT’S THE PURPOSE AND ARE THERE ANY ALTERNATIVES?

When an individual has gross hematuria or persistent microscopic hematuria, a complete assessment of the urinary tract is required. Although cystoscopy is the test of choice for examination of the bladder, imaging studies are required to make sure there is no disease in the upper tracts (kidneys and ureters). Bleeding can be caused from many different disorders including transitional cell carcinoma of the upper tracts, kidney or ureteral stones, or renal cell carcinoma (cancer of the parenchyma or fleshy part of the kidneys). Your urologist has a number of options to choose from. There are advantages and disadvantages of each.

Intravenous pyelogram (IVP) is accomplished by injecting a contrast agent into your vein and then obtaining X ray images. The contrast is excreted by your kidneys, subsequently filling the lumen of the kidneys, ureters and the bladder. The contrast allows one to see subtle filling defects within chambers of the urinary tract, possibly representing tumor, stone or blood clot. Tumors of the fleshy part of the kidneys can also be seen. The study also allows for an assessment of renal function. It is a sensitive test for renal obstruction, which can occur because of cancer. Disadvantages of the study include the possibility of an IV contrast agent allergy, which occasionally may be serious.

You will be asked whether you have a sea food allergy, a known allergy to iodine or to IV contrast. If this is the case, you may need to be premedicated prior to the exam to avoid a reaction. Although the study is quite useful at visualizing the upper tracts, it is not very good at picking up subtle tumors on the bladder surface. If your kidneys do not function well (you have renal insufficiency), the contrast may cause harm to your kidneys and the imaging will not be as good. For pregnant women, any X ray exam could be potentially damaging to the fetus and therefore, will not be performed.

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Ultrasonography can check for a kidney tumor, stone, or obstruction. Bladders filled with urine can be scanned. There is no contrast or X rays involved, and therefore the study can be accomplished in those with renal disease, contrast allergies or for women who are pregnant. Although larger tumors of the bladder are often visible, it is not a good study to rule out urothelial cancer (transitional cell cancer of the urinary tract lining) since smaller tumors or flat tumors in the lining are not visible. Also, other conditions such as enlarged folds in the bladder or enlarged prostates can be confused with bladder tumors. Ultrasound exams are generally fast, painless, and relatively inexpensive. An ultrasound combined with cystoscopy plus cytology (to rule out cancer cells) is a reasonable assessment for those with a low likelihood of having upper tract disease.

CT Scan or CAT (computerized axial tomography) provides a computerized cross sectional visualization of the abdomen and pelvis. X ray images are synthesized into exquisitely detailed images. The CT scan can be done with or without IV contrast, and therefore has the same limitations as IVP in those with allergies to contrast or renal insufficiency. These studies are excellent for finding renal cell cancers and stones within the kidneys and ureter, but not very good at delineating cancers of the lining. CT scan is often an important part of staging bladder cancer, determining whether the cancer has spread.

Magnetic Resonance Imaging (MRI) is a technology which uses strong magnets to provide detailed images of your internal organs. Like ultrasound, this study has no known harmful effects on the body. It does not require contrast injection like CT scan and can be done safely in patients with renal insufficiency. It is not generally used for initial screening. Many individuals find the test uncomfortable due to a loud noise heard throughout the test, in addition to the close quarters the machine requires, leading to feelings of claustrophobia. A mild sedative may be required if the test is necessary and the individual experiences these uncomfortable feelings.

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MY FAMILY WANTS ME TO GO FOR TREATMENT OF MY BLADDER CANCER TO THE “TEACHING HOSPITAL” IN THE CITY MY LOCAL UROLOGIST IS COMPETENT AND CARING AND I TRUST HIS JUDGEMENT SHOULD I LISTEN TO MY FAMILY AND SWITCH UROLOGISTS?

As we have discussed in the preceding questions, finding an excellent urologist to partner with is a must. A physician established at a “teaching hospital” (a hospital where physicians are trained in their respective fields of specialty) is at the minimum, competent. A large teaching or academic center would not risk its reputation on an individual who is sub par. Some individuals may be world class surgeons, but not all will be. An individual may be an average surgeon, but a gifted teacher or researcher, making them invaluable to their academic center. Your local community urologist will likely be an individual trained at one of these academic teaching hospitals. In addition, community hospitals also have credentialing and quality review programs to weed out incompetent physicians. In general, it is true the academic center will have more stringent standards and review of their staff. Nevertheless, excellent physicians can be found at the community hospital as well.

ISN’T IT TRUE THAT ACADEMIC OR TEACHING HOSPITALS WILL HAVE THE BEST TECHNOLOGY OR MOST UP TO DATE INFORMATION TO TREAT MY CANCER?

These hospitals generally are at the forefront of innovation regarding technological advances, testing and implementation of new surgical techniques and chemotherapeutic regimens. However, no one center can be excellent in all spheres of medicine. Each will have particular strengths and weaknesses. We are however, fortunate medical knowledge and innovation are shared openly via medical journals and conferences and other means of information exchange. New information and proven effective techniques are rapidly disseminated throughout the medical community. Some teaching hospitals may be “centers of excellence” for a particular procedure or innovative approach that is available at only a few sites in the country. There is naturally a lag time for some procedures to spread to the local level, and if in fact a new procedure carries substantial benefits compared to the standard, and is not available locally, then a referral may be appropriate.

Medical information is scrutinized in journals and reviewed at conferences. The newest treatment regimens for advanced cancer are explored in clinical trials to determine their efficacy and safety. It is only after they are proven that they become adopted as standard practice by most physicians. For the vast majority of individuals with bladder cancer, excellent, comprehensive treatment can be obtained at the local level. For those requiring more specialized care or for those unfortunate individuals with advanced cancer who desire experimental therapy via a clinical trial for their cancer, a referral to the appropriate center may be appropriate.

IF I HAVE MY MAJOR SURGERY PERFORMED AT A TEACHING HOSPITAL, WILL THE ATTENDING PHYSICIAN PERFORM MY SURGERY AND TAKE CARE OF ME AFTERWARDS?

At a teaching hospital, physicians are in training to master their skills before going out into “practice” in their respective fields. Interns are fresh out of medical school with limited practical training. Often they are referred to as PGY 1 (post graduate year 1). Years of training follow (PGY2, PGY3 etc.). Urology residents are required to generally have at least two years of training in a surgical program followed by four years in urology residency. It is the responsibility of the residency director to provide adequate training for these future urologists while assuring patient safety. Practically speaking, there are usually one or more attending physicians who supervise the work of the physicians in training. The attending physicians are board certified, experienced physicians who treat patients while simultaneously training physicians. The residents will be a key component in your care. They will be assessing you both pre- and post-operatively and will be writing orders directing your care. How much of the surgery they get to do is dependent on their years of training and their skills. They will be under the direct supervision of the attending physician. If you have concerns, you should address them with your attending physician.

MY UROLOGIST ALWAYS KEEPS ME WAITING, DOES THIS MEAN HE DOESN’T CARE?

Given the monetary pressures in today’s medical practice, some physicians are over booked and cannot see the allotted number of patients scheduled without delays. The theory behind this schedule is the expectation that a number of patients will not show for their appointment, allowing the physician to stay true to the schedule and not fall behind.

However, sometimes all of the patients do show, and the physician is delayed. Even with a carefully thought out schedule, emergencies may arise and some visits unexpectedly take longer than scheduled. The physician wants to devote the time and attention required for each individual. After all, you also expect the same time and attention during your visit. Even the most conscientious physician may find himself running behind in a busy medical practice. This lateness should be recognized by the physician who will often acknowledge it with an apology. If you find it distressing to wait more than fifteen minutes (a reasonable time to wait), you should discuss your feelings with your physician, who often can arrange an appointment at the beginning of the schedule when he will almost be guaranteed to be on time.

WILL THERE BE OTHER PHYSICIANS INVOLVED IN MY TREATMENT OF BLADDER CANCER?

You may need to be referred to an oncologist, a physician specialist in the medical therapy of cancer. At times, a referral to a radiation oncologist, a specialist who treats cancer with radiation, may be required. Other individuals may need to be consulted as well. It is important for your urologist to keep your primary care physician up to date so that he can coordinate your care and if required by your insurance plan, make the appropriate referrals.

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On a regular basis, magazine articles, books, and television shows implore those with major illnesses to seek out a second opinion. The general consensus is there is much to be gained and little to be lost, so why not seek out a second opinion? The issue certainly is more complicated than generally addressed, and deserves a review. The following chapter provides a second opinion on second opinions.

WHAT ABOUT SECOND OPINIONS?

In general, a competent physician will recommend a second opinion if there is uncertainty regarding your care. This uncertainty could involve the pathology report or debate regarding the most appropriate treatment options. Certainly if the pathology report is in question, a second opinion is mandatory! Your urologist should be able to spell out his treatment plans for you, what to expect and what alternatives may be required, depending on the seriousness of your disease. The plan may change over time as your disease improves or worsens.

You may need a second opinion if you are not doing well and your physician is unable to provide satisfactory explanations and solutions. Occasionally, your urologist may recommend a second opinion if your problem is unusual or particularly complicated. Having a physician you can trust is mandatory when dealing with cancer. Don’t let anyone pressure you into a second opinion if you feel confident in your physician’s abilities. On the other hand, if you are uncomfortable with your progress or a treatment recommendation, if you are not satisfied with the explanations given to you, don’t hesitate to seek out a second opinion. Your urologist should not feel threatened by this request as he wants you to feel comfortable with the plan of action. Only by partnering with your physician can he be most effective.

WILL MY UROLOGIST BE UPSET WHEN I REQUEST A SECOND OPINION?

Many physicians may feel slighted when a patient requests a second opinion. Your urologist may feel somehow you don’t trust his explanations, skill, or judgment. On the other hand, when a new patient faces a difficult or unexpected diagnosis, the urologist may find the request not at all unusual. It is important you explain to your urologist why you feel a second opinion is warranted. Urologists are professionals and will graciously facilitate your request. The experienced urologist comes to realize that despite his best efforts, some patients will seek a second opinion. If a patient is particularly concerned or nervous about a proposed treatment regimen, your urologist may welcome your request. Your urologist should facilitate your second opinion by sending appropriate records and telling you whether or not it is necessary for you to bring X rays or pathology slides with you. Your primary care physician may need to be contacted for the referral if your insurance requires it.

WHY DOESN’T MY UROLOGIST WANT ME TO GO FOR A SECOND OPINION?

Often, the urologist may believe the second opinion is unnecessary and will delay treatment. He may be concerned you will not only have a second opinion, but transfer your future care to the urologist providing the second opinion. He may believe that you may get bad advice. It is possible he may feel threatened the next urologist will not agree with his work up or care of you to date.

WHERE DO I FIND A SPECIALIST FOR A SECOND OPINION?

Start by asking your primary care physician. You may be able to see another urologist in your community. Do not see another urologist in the same group as a conflict of interest may deter a different opinion. If you are considering a different course of action, such as radiation or chemotherapy, a referral to the appropriate specialist should be made.

Many times your urologist will be highly supportive and suggest a second opinion. He will offer his recommendations and facilitate your visit to the appropriate physician. If there is an issue regarding the care given at your local hospital, you may wish a referral to a “tertiary” or teaching hospital. In most areas, a referral for this reason is unnecessary, as excellent care is obtainable in the community hospital.

Our use of the term or terms Actos Side Effects is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Side Effects : WHAT IS THE FUNCTION OF THE BLADDER?

A bladder stores urine and expels it at a convenient time. The bladder is a very useful organ, (tissues working together to accomplish a function), but an individual can live a normal life without one, if required, by surgical creation of a substitute.

ARE THERE DIFFERENT TYPES OF BLADDER CANCER?

More than 90% of bladder cancers arise from the lining bladder cells called transitional cells. Bladder cancer is almost always transitional cell cancer. These cells are also present in the urethra (the body tube which drains the bladder), as well as the renal pelvis (inner lining of the kidneys), and the ureters (the body tube draining the kidneys).

Bladder cancer can vary from the non serious, low grade superficial type (approximately 70%), to the invasive, aggressive type that can spread and prove to be fatal (approximately 30%).

5% of bladder cancer is accounted for by squamous cell carcinoma. This cancer is usually secondary to long term inflammation or infection of the bladder. Even rarer is adenocarcinoma, which accounts for less than 2% of all bladder cancers.

HOW COMMON IS BLADDER CANCER?

The American Cancer Society estimates that in 2006,61,420 new cases of bladder cancer were diagnosed in the United States with approximately 73% of those occurring in men. In the same year, this cancer caused approximately 13,060 deaths with approximately two out of three of those being in men. The disease is more common in whites than blacks. The incidence of bladder cancer increases with age in both sexes. When bladder cancer occurs in young people, it tends to grow slower and not be as serious. In men, it is the fourth most common cancer. However, because of the rate of recurrences and long term survival, it is the second most prevalent cancer in middle aged and elderly men. In women, it is the eighth most common cancer. The average age at diagnosis is 65. Over the past decade, there has been both an increased incidence, but also an increased rate of survival for bladder cancer ^[1]

WHAT CAUSED MY CANCER?

A mutation is a disruption in the DNA of a cell, leading to a loss of regulated cell growth. Mutations can occur spontaneously as we age. It is truly amazing that all of us don’t develop cancer as we are composed of trillions of cells dividing regularly over decades. Fortunately, our cells have repair mechanisms which can often fix damaged cells before cancer arises. In addition, the immune system can destroy cancer cells before they have a chance to grow into tumors.

Mutations and cancer can also be triggered by environmental factors. Certain chemicals have been identified to be particularly effective at inducing mutations in our DNA and subsequent cancer. These chemicals are called carcinogens. Smoking is the most common culprit! Cigarette smoking has a strong link with bladder cancer. Studies have shown approximately 50% of bladder cancer is secondary to tobacco smoke. Smoking releases dozens of carcinogens into the lungs and then into the blood stream. Many of these carcinogens are excreted by the kidneys.

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IT IS TOO DIFFICULT TO QUIT SMOKING; IS THERE ANY SURE FIRE WAY TO QUIT?

Tobacco smoke contains nicotine, an extremely addictive chemical. Men overall find it easier to quit smoking than women. When facing the prospects of losing your bladder to cancer or possibly your life, most individuals will become convinced and many simply stop smoking “cold turkey.” Unfortunately, many choose not to quit until their cancer repeatedly recurs or becomes invasive, needlessly placing their health at risk. For those who need assistance in quitting, nicotine patches, gum, and lozenges are all available over the counter. These products allow the smoker to quit without experiencing the discomfort of withdrawal from nicotine. Many smokers also find hypnosis or support groups useful. In addition, prescription medication is available.

ARE THERE ANY OTHER KNOWN CAUSES?

Occupational exposure may account for up to 20% of bladder cancers. Those exposed to aniline dyes (used to color fabrics), aldehydes (used in chemical dyes and in the rubber and textile industries) and those using organic chemicals (used in a wide range of occupations) are all at increased risk. Individuals previously treated with radiation to the pelvis or having received cyclophosphamide (a type of chemotherapy) are at markedly increased risk for developing bladder cancer. If your well water is high in arsenic, your risk may also be increased. Studies have also correlated obesity and a high fat diet, especially with increased cholesterol, as a possible contributing factor.

CAN I HELP TO PREVENT BLADDER CANCER BY DRINKING MORE FLUIDS?

Surprisingly, the answer may be yes. In a recent study, the relationship of diet to cancer was analyzed in a group of47,000 health professionals.^[1] In the case of bladder cancer, those who drank the most fluid (greater than 10 cups/day) had half the risk as those who drank the least (less than 5 cups/day). The type of nonalcoholic beverage was less important than the total amount.

WILL MY CHILDREN BE AT HIGHER RISK OF DEVELOPING BLADDER CANCER?

Although there have been clusters of bladder cancer reported, most researchers believe these may be secondary to risk factors such as smoking and exposure to carcinogens. At this time, there is no convincing evidence bladder cancer risk is hereditary. If an environmental factor caused your cancer and your children are exposed as well, their risk of cancer may be increased.

WHAT IS CANCER?

The basic building block of the body is the cell. Cells are specialized to perform a particular function. Skin cells are distinctly different from liver cells which are different from bladder cells. An organ is composed of various cells working in unison to carry out a body function. Cells eventually get old and die. New cells are created by cell division. When cells are behaving normally, they only generate enough new cells to replace the old dying ones. Occasionally, cell growth becomes unchecked. As the cells continue to divide, a tumor (abnormal growth of cells) may form. Such tumors may be benign (no ability to spread beyond their organ of origin) or cancerous (a malignant tumor with the ability to spread beyond their organ of origin and cause harm and possibly death).

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HOW CAN I TELL IF MY BLADDER CANCER IS LIKELY TO SPREAD?

Larger tumors are more likely to spread than smaller tumors. Another critical concern is the grade of the tumor. Normal cells are specialized, differentiated to perform specific function, and have a typical structural arrangement with surrounding cells. As cancers worsen, the cells become less specialized, less differentiated, and lose their normal structural arrangement, resulting in a higher pathologic grade.

In the case of bladder cancer, pathologists classify them into 3 grades based on a number of criteria:

Grade 1: low grade, well differentiated Grade 2: intermediate grade, moderately differentiated Grade 3: high grade, poorly differentiated The higher grade tumors have a greater propensity to metastasize- spread throughout the body.

For bladder cancer, another key indicator for likelihood to spread is the depth of penetration into the bladder wall. The bladder wall is composed of an inner lining called the urothelium (made up of transitional cells) which rests on a membrane layer called the basement membrane, below which is the connective tissue layer (support tissues) called the lamina propria. Within the lamina propria lies a small amount of muscle called the muscularis mucosa. Deep to the lamina propria is the deep muscle of the bladder arranged in three layers. This layer is called the muscularis propria. Tumors located in the inside, superficial layers of the bladder wall are unlikely to spread. Tumors that grow into the deeper layers (down into the muscle of the bladder wall) are much more likely to spread. Furthermore, there is a definite link between the grade of the tumor and its likelihood of invasion. Low grade tumors are almost always noninvasive, while high grade tumors are usually invasive. In general, papillary tumors, which are delicate and frond like in appearance are usually low grade and superficial. This is to be contrasted to sessile tumors which appear solid, are often high grade and invasive. Depth of invasion is critical in establishing prognosis. The tumor which invades into the lamina propria is a far more serious tumor than the superficial tumor which demonstrates no invasion. It has a much higher propensity to progress to the muscle invasive tumor, a much more dangerous cancer, with a high risk for spreading beyond the bladder. For further information see Chapter 6.

Our use of the term or terms Actos Side Effects is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Side Effects atients sometimes describe feeling some abdominal pressure or discomfort, but not pain, during the flexible cystoscopy procedure. You will be awake, wearing a gown and lying on an examining table, with your knees draped and held apart. As noted above, your doctor will use anesthetic gel to numb the area where the flexible tube is inserted and then gently guide the cystoscope into the urethral opening (the eye of the penis in a man; the vaginal outlet of the urethra in a woman). Some men experience brief pressure and discomfort as the cystoscope passes over the area where the prostate is located. In most cases, the entire process, including preparation, will take about 15 to 20 minutes, and your doctor will be able to discuss the results of the flexible cystoscopy with you immediately.

The rigid cystoscopy is sometimes done when the tumor is in an inaccessible part of the bladder as well as when a more complicated biopsy is needed. It is performed in a hospital setting and can be either an inpatient or outpatient procedure. While the process is similar to flexible cystoscopy, you will be given general anesthesia and a more rigid tube will be used. Your doctor will give you specific instructions about how to prepare for the anesthesia (you will need to have someone drive you to and from the hospital) and what to expect during the brief recuperation after the procedure. You may be asked to remain overnight if you have other medical problems, such as severe heart disease.

During the IVP, you’ll be lying on a flat table, wearing a hospital gown, with the x-ray machine positioned above you on a movable jointed arm. The radiologist will take some basic x-rays and then will inject a contrast substance (usually iodine) through a vein, usually in your arm. The iodine is carried by the blood system to the kidneys, where it is removed (excreted into the urine). The iodine shows up when exposed in an x-ray. You might feel a sense of heat or burning from the iodine or have a metallic taste in your mouth. However, these sensations usually disappear after a few minutes. If you know that you are allergic to iodine, let the radiologist know and a different contrast material can be used.

As the iodine travels through your urinary tract system, a quick series of x-rays is snapped. Sometimes the radiologist will apply a gentle compression elastic band around your body to help the visualization process. You may be asked to turn over and might even be asked to empty your bladder. (The iodine should not cause any discoloration of your urine or any pain or burning during urination.) The x-rays taken before the iodine was injected and those taken after provide images for your doctor that give a visual picture of the ureters (the tubes between the kidneys and bladder) and the bladder’s anatomy and function.

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The technologist then moves a transducer (an imaging gadget shaped somewhat like an oversized electric shaver with a flat head) over the area where the bladder is located. You probably will be asked to change positions or even to hold your breath for a few seconds during the process. The technologist watches on a screen to make sure that clear images are being recorded.

If any of the tests suggest the presence of a bladder tumor, your doctor will schedule other tests; they might include an MRI or a CT scan, and if a biopsy was not obtained during the flexible cystoscopy process, a surgical biopsy as well. These tests help your doctor determine where the tumors are, what type of cancer you have, and whether the cancer has invaded the muscle wall of the bladder. Depending on the results of those tests, your doctor may order a chest x-ray or even a bone scan to determine whether the cancer has spread to other areas of the body.

A CT scan is a painless, noninvasive test during which low intensity x-rays are repeatedly passed through the body’s soft tissue at different angles. A computer then processes the x-rays to show a detailed cross-section of the tissues and organs – in your case, of the bladder, liver, spleen, abdominal lymph nodes, and surrounding tissues. Sometimes the scanner will be focused on the chest and lungs to see whether cancer has spread there. From the CT scan, your doctor not only can confirm the presence of a tumor in the bladder, but can also measure its size and location, and determine whether it has spread to other nearby tissue.

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The CT scanner can snap about 32 cross-section pictures or “slices” in approximately 10 seconds as the machine moves over your body. This means that you can easily hold your breath as the images are taken. For the CT scan, you’ll be lying on a table, dressed in a gown, and while you’ll be able to talk with the radiology technicians at all times over an intercom, you’ll be alone in the room and asked to lie still and hold your breath while the actual x-rays are being taken.

Like the IVP, a contrast medium is used to help the radiologist see your bladder and urinary tract. Sometimes it may be injected into the veins, as in IVP, or it may be swallowed or sometimes administered as an enema to distinguish bowel tissue from the bladder structure. Usually when diagnosing bladder cancer, doctors will want all three – intravenous, oral, and rectal scans – to help determine how deeply tumors may have invaded the bladder tissue and whether there is any spread to the abdominal lymph nodes or liver.

Some people find the taste of the contrast medium unpleasant, and if an enema is required, you’re likely to feel a brief, uncomfortable fullness while the scans are being taken. However, because of the speed of the process, the feeling that you need to expel the contrast medium doesn’t last long. You might also feel a brief flush or hot sensation when the contrast medium is injected. A CT scan takes anywhere from 5 to 30 minutes. Other than mild discomfort, there are few side effects.

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Actos Side Effects : Sometimes, in an alternative procedure/ lasers (high-energy light beams) are used to remove superficial TCC tumors. While this is slightly more comfortable than resection for you as a patient, the laser often destroys the tumor tissue, leaving nothing for pathologists to examine. The lack of pathology may limit your medical team’s ability to predict recurrence and target your follow-up plan.

If you have been diagnosed with a low-risk tumor, resection may be the only treatment recommended by your medical team. Or your team may recommend a course of intravesical therapy, too. Intravesical is a medical term meaning “within the bladder/’ Intravesical therapy, therefore, means that treatment – in this case a solution containing anti-cancer drugs – is placed directly in the blad­der instead of being given to you as a pill to swallow or as an injection.

The treatment is given as a liquid poured through an ordinary uri­nary catheter, the same device that is usually used to drain urine from the bladder. In this case, the flow of fluid is reversed, with the med­ication being injected gently up through the catheter into the inside of the bladder. Think of it this way: Remember when you were a kid and filled balloons with water? If you imagine the bladder as that bal­loon, filled not with water but with liquid medication sloshing around inside, you’ll ‘have a good idea of how intravesical therapy works.

Intravesical therapy has been used for about 30 years as a preven­tive treatment to reduce the recurrence rate for superficial bladder cancer. It is believed that intravesical therapy works because it destroys cancer cells that may remain “floating” in the bladder after resection, thereby reducing the possibility of a recurrence. It also may be absorbed directly into any remaining tumor tissue, causing destruction of the tumor. There are two types of intravesical therapy, chemotherapy and immunotherapy, with numerous treatment options within each therapy group.

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Your medical team will take a number of things into consideration when deciding which intravesical treatment option is best for you. Their goal is to balance the effectiveness of the treatment with possi­ble side effects and long-term risks based on the type and seriousness of your cancer. Aggressive treatment options with possibly serious side effects may well be the right choice if you’re dealing with a type of cancer that has a high recurrence rate and often comes back in a more life- threatening form. On the other hand, if your cancer is low risk and has a lesser chance of recurring, a more conservative approach might be taken.

Regardless of whether you’re advised to take chemotherapy or immunotherapy both are administered the same way The procedure can be performed either at the hospital about one to seven days after your resection or in your doctor’s office if a series of weekly treat­ments is recommended. The timing depends somewhat on how extensive the resection has been.

First your doctor will numb your urethra with a topical gel and insert a disposable catheter, which wall be used to fill the bladder with the solution. The catheter is removed after your bladder is full, and you’ll be asked to concentrate on not passing urine for a time, hold­ing the solution inside while you get up and move around. Walking, sitting, and standing while the solution is held in your bladder caus­es it to slosh around and completely coat inside the bladder walls. After an hour or so, you’ll void the solution just as you would pass urine. In most cases, you’ll be asked to minimize your fluid intake before the procedure so that your bladder won’t also be filling with urine that wall put additional pressure on your bladder.

The chemotherapy drugs that are used in this way include doxoru­bicin (brand name Adriamycin), epirubicin (Pharmorubidn), mitomycin C (Mutamydn), and occasionally thiotepa (Thioplex). Chemotherapy solutions have proved effective in reducing recurrence rates by about 30 percent. However, chemotherapy has little or no effect in prevent­ing superficial cancer from progressing to a more serious stage. What this means is that chemotherapy will often stop the superficial cancer

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Although BCG is highly effective, it also has some toxic side effects, and as such is used primarily as a treatment for patients with high-risk types of superficial bladder cancer and those who have had repeated recurrences or CIS. Side effects may include a burning sensation in the bladder as well as fatigue, chills, and fever. A prolonged high fever and general feel­ing of being ill may be a sign that the BCG bacteria have spread through the body. Because BCG is the bacterium that causes a type of tuberculosis, antibiotics used to treat tuberculosis are usually pre­scribed when an infection occurs shortly after BCG immunotherapy. Another type of immunotherapy is interferon.This is naturally pro­duced in your body’s cells and works much as BCG does in stimulat­ing your body to attack cancer cells in the bladder. Temporary side effects, which usually disappear once interferon therapy is stopped, include muscle and bone aches, fatigue, vomiting, and headaches.

In almost all cases, intravesical therapy (chemotherapy or immunotherapy) is most effective when the first dose is given 6 to 24 hours after resection. Sometimes a single dose is given as a prophy­lactic (preventative) measure and is not repeated. More commonly, you’ll have one dose immediately after resection and then five more treatments on a weekly basis in your doctor’s office. In some cases, if a large tumor has been resected, leaving a larger area of ulcerated bladder surface, intravesical chemotherapy will be delayed for a few days to prevent the drug’s being absorbed through the damaged sur­face lining of the bladder. Your doctor may recommend a follow-up cystoscopy after the intravesical treatments are completed.

Keep in mind that there are several types of superficial bladder cancer, some of which have a high risk of recurrence or progression to a more serious stage. Treatment options, including resection and intravesical therapy, are different for each person and depend upon each person’s circumstances, For example, you may start talking to someone in your urologist’s waiting room who has had great results and few side effects from a single dose of mitomycin C (MCC) chemotherapy. Even more impres­sive, he hasn’t had a recurrence since his diagnosis three years ago. You, on the other hand, are on your fourth BCG treatment, and each one leaves you feeling as if you have severe bladder irritation for several days afterwards. “No side effects and no recurrences” sounds like a better deal than what you’re experiencing. So why wasn’t MCC prescribed for you?

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Actos Side Effects: In general, a competent physician will recommend a second opinion if there is uncertainty regarding your care. This uncertainty could involve the pathology report or debate regarding the most appropriate treatment options. Certainly if the pathology report is in question, a second opinion is mandatory! Your urologist should be able to spell out his treatment plans for you, what to expect and what alternatives may be required, depending on the seriousness of your disease. The plan may change over time as your disease improves or worsens.

You may need a second opinion if you are not doing well and your physician is unable to provide satisfactory explanations and solutions. Occasionally, your urologist may recommend a second opinion if your problem is unusual or particularly complicated. Having a physician you can trust is mandatory when dealing with cancer. Don’t let anyone pressure you into a second opinion if you feel confident in your physician’s abilities. On the other hand, if you are uncomfortable with your progress or a treatment recommendation, if you are not satisfied with the explanations given to you, don’t hesitate to seek out a second opinion. Your urologist should not feel threatened by this request as he wants you to feel comfortable with the plan of action. Only by partnering with your physician can he be most effective.

Many physicians may feel slighted when a patient requests a second opinion. Your urologist may feel somehow you don’t trust his explanations, skill, or judgment. On the other hand, when a new patient faces a difficult or unexpected diagnosis, the urologist may find the request not at all unusual. It is important you explain to your urologist why you feel a second opinion is warranted. Urologists are professionals and will graciously facilitate your request. The experienced urologist comes to realize that despite his best efforts, some patients will seek a second opinion. If a patient is particularly concerned or nervous about a proposed treatment regimen, your urologist may welcome your request. Your urologist should facilitate your second opinion by sending appropriate records and telling you whether or not it is necessary for you to bring X rays or pathology slides with you. Your primary care physician may need to be contacted for the referral if your insurance requires it.

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More than 90% of bladder cancers arise from the lining bladder cells called transitional cells. Bladder cancer is almost always transitional cell cancer. These cells are also present in the urethra (the body tube which drains the bladder), as well as the renal pelvis (inner lining of the kidneys), and the ureters (the body tube draining the kidneys). Bladder cancer can vary from the non serious, low grade superficial type (approximately 70%), to the invasive, aggressive type that can spread and prove to be fatal (approximately 30%). 5% of bladder cancer is accounted for by squamous cell carcinoma. This cancer is usually secondary to long term inflammation or infection of the bladder. Even rarer is adenocarcinoma, which accounts for less than 2% of all bladder cancers.

A mutation is a disruption in the DNA of a cell, leading to a loss of regulated cell growth. Mutations can occur spontaneously as we age. It is truly amazing that all of us don’t develop cancer as we are composed of trillions of cells dividing regularly over decades. Fortunately, our cells have repair mechanisms which can often fix damaged cells before cancer arises. In addition, the immune system can destroy cancer cells before they have a chance to grow into tumors.

Mutations and cancer can also be triggered by environmental factors. Certain chemicals have been identified to be particularly effective at inducing mutations in our DNA and subsequent cancer. These chemicals are called carcinogens. Smoking is the most common culprit! Cigarette smoking has a strong link with bladder cancer. Studies have shown approximately 50% of bladder cancer is secondary to tobacco smoke. Smoking releases dozens of carcinogens into the lungs and then into the blood stream. Many of these carcinogens are excreted by the kidneys. After years of being exposed to this toxic soup, a smoker’s bladder has a much greater chance of developing bladder cancer, two to three times, and in heavy smokers up to five times the rate compared to those people who have never smoked. The risk clearly correlates with the number of years the individual has smoked and the number of cigarettes smoked per year. Fortunately, after you stop smoking, your risk gradually decreases. Once you develop bladder cancer, it is mandatory to stop smoking. It is now known failure to stop smoking leads to a much worse outcome compared to those with bladder cancer that stop smoking.

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Tobacco smoke contains nicotine, an extremely addictive chemical. Men overall find it easier to quit smoking than women. When facing the prospects of losing your bladder to cancer or possibly your life, most individuals will become convinced and many simply stop smoking “cold turkey.” Unfortunately, many choose not to quit until their cancer repeatedly recurs or becomes invasive, needlessly placing their health at risk. For those who need assistance in quitting, nicotine patches, gum, and lozenges are all available over the counter. These products allow the smoker to quit without experiencing the discomfort of withdrawal from nicotine. Many smokers also find hypnosis or support groups useful. In addition, prescription medication is available.

The basic building block of the body is the cell. Cells are specialized to perform a particular function. Skin cells are distinctly different from liver cells which are different from bladder cells. An organ is composed of various cells working in unison to carry out a body function. Cells eventually get old and die. New cells are created by cell division. When cells are behaving normally, they only generate enough new cells to replace the old dying ones. Occasionally, cell growth becomes unchecked. As the cells continue to divide, a tumor (abnormal growth of cells) may form. Such tumors may be benign (no ability to spread beyond their organ of origin) or cancerous (a malignant tumor with the ability to spread beyond their organ of origin and cause harm and possibly death).

Our use of the term or terms Actos Side Effects is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Side Effects:  Bladder cancer, or any serious potentially life threatening illness is generally alien to most individuals. Suddenly, lives are changed and a new reality must be dealt with. Becoming a “patient” or worse “a cancer patient” is not only threatening, but a dreaded proposition. Cancer patients are not happy with the loss of autonomy, the invasion of privacy, the discomfort inflicted upon them and the demands on their time and quality of life. As a patient, being thrust into this altered identity, it is essential to seek out the information you need. Having a fundamental base of knowledge is a must when facing the issues and treatment decisions which lie ahead. In the following pages, together we will explore bladder cancer, a disease which is totally foreign to most of us until the diagnosis is made. I have chosen to present the information in a question and answer format, written in a conversational tone, as if I were having an extended consultation with one of my patients. The questions are typical of what individuals have asked over the years. 1 have covered the key issues and decisions the individual with bladder cancer may face. The answers are to the point and cover the essentials required to make an informed decision for most individuals. For others, a more detailed resource may be required.

Each individual’s situation is unique. Decisions on treatment may be modified based on the patient’s preferences and values and altered by other considerations such as age and coexisting conditions. By becoming an individual knowledgeable of bladder cancer, you will be prepared to fully partner with your physician for your best possible outcome. To your companions and family members, this book will serve to answer the many questions and doubts that may arise. Having your loved ones informed and supportive is a big plus for the individual facing this new challenge.

The book is written in a logical sequence starting with finding a qualified urologist to the basics on bladder cancer, its assessment and treatment. At the end of the book, you will find chapters on complementary medicine, advance care planning, and hospice care. The book can be read in sequence or each chapter can serve as a resource covering the basics of the topic. It is my hope this book will help clarify the many issues and options individuals must face with bladder cancer. For family members, significant others and concerned friends, this resource should help improve your understanding and thus your ability to assist your loved one.

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A urologist board certified by The American Board of Urology has gone through an accredited urology training program (generally a four year program), following two years of internship and residency in surgery after four years of medical school. The urologist must be in practice after training and provide a detailed list of surgeries, including complications, over a twelve month period. The doctor will then take a two day oral and written test covering a wide spectrum of urology. If he passes, he is certified for a period of ten years. At the end of the ten year period, he must recertify to maintain his board status. Recertification entails a three month surgical and procedure log and a written test as well as reference letters from those in a position to judge the practicing urologist’s work. Any malpractice or judgments are also reviewed. Although being board certified does not guarantee you have an excellent urologist, it demonstrates that he has the fund of knowledge to practice urology competently. Even though board certification is voluntary, in today’s competitive environment more and more hospitals and insurance plans are requiring their specialists to be certified.

Surgery is a skill which can only be mastered with experience. The saying “practice makes perfect” definitely pertains to surgery. Although a urology training program offers the new physician years of training, his surgical skills will continue to improve with further experience. However, each individual physician has his own innate skills. Some more quickly learn and are simply better at the technical craft of surgery than others. For the most part, urologists finishing an accredited urology program have the training and skill set required to care for patients with bladder cancer. Experience also counts. As a physician practices the art of medicine, his depth of knowledge and ability to treat grows. Ask your physician how long he has been treating patients with bladder cancer. If you require major surgery ask how many he has performed and if his complication rate matches what is expected.

Physicians by and large do improve as they practice, and all physicians are required to show that they are continuing to learn by partaking in continuing medical education, a requirement to remain licensed. Most physicians are compulsive in their medical practice and care deeply in the care they deliver. They continually strive to improve.

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Your urologist must be an individual who takes your concerns, priorities and values seriously. Your urologist should be a good communicator. It is his responsibility to keep you fully informed of your progress, make you aware immediately if things are not going well, and educate you fully in treatment alternatives. Your specific values should be incorporated into the decision process if alternatives are available. Even if your urologist makes a recommendation and you choose an alternative course (unless you are putting yourself in extreme jeopardy), he should honor your choice and continue his care of you. Becoming an educated patient will make your decision making process easier. Granted, your physician should provide you with the basics, however having time to review and digest the material will allow you to fully understand and accept your treatment regimen, providing you with peace of mind.

Beware of the physician who bombards you with statistics and studies and leaves the decision making to you. After all, you are not a physician and don’t have the practical hands on experience he does. Your physician should provide the facts and the statistics, guide you through the information, and make treatment recommendations based on your preferences.

You may find yourself emotionally distraught and overwhelmed. Having a physician on your side is invaluable. You should be able to trust your physician. Complete honesty on the part of your doctor in his care of you is a must. From the doctor’s point of view, trust is also a necessity. Physicians have an extremely difficult time dealing with individuals who do not trust them. Without trust, the physician patient relationship is extremely hindered.

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Actos Side Effects : There is a small risk of infection after surgery. Post- surgical infections can occur in the abdominal wound, intra-abdominally at the site of bladder removal, and also in the urine (urinary tract infection) or kidney (pyelonephritis). Most infections can be successfully treated with antibiotics. Wound infections can require a portion of your incision to be opened to allow drainage of infected material. This is easily done at the bedside and is not painful. Once the infection clears, the wound heals on its own without any further therapy.

Gastrointestinal (GI) complications and side effects are extremely common after cystectomy, mainly due to the bowel surgery that is required for urinary diversion. Anywhere from 30-60 percent of patients will have a postoperative ileus. Ileus occurs when there is temporary decreased motility of the intestine after surgery. Common causes of ileus are edema related to the bowel anastomosis, electrolyte imbalances and fluid shifts that can occur with surgery, anesthetic effects on the bowel, and retraction of the bowel at the time of surgery. The symptoms of ileus are abdominal bloating, decreased appetite, inability to pass gas, nausea, and vomiting with food intake. The treatment for ileus is to not eat or drink anything until GI motility returns.

In doing so, abdominal distention, nausea, and vomiting can be minimized. Most cases of ileus resolve within a few days. Small bowel obstruction, which has similar symptoms to that of ileus, can occur early in the postoperative period or many years after your initial surgery. In this case there is an actual obstruction of the bowel, generally at the site of the anastomosis. Occasionally, this can be managed conservatively in much the same manner as described with an ileus, but often surgery is required to relieve the obstruction. Bowel habits can also change after cystectomy. This can range from constipation, to loose stools, to frank diarrhea. These symptoms are caused by the removal of the portion of intestine that is used for urinary diversion. As one can imagine, these symptoms tend to be worse in patients who have continent urinary diversions because larger segments of bowel are used. Many of these symptoms can be treated successfully with over-the-counter medications that either help with constipation or add bulk to the stool in cases of diarrhea.

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There are medical risks associated with any major surgery, and cystectomy is no exception. These risks include deep vein thrombosis (blood clots in the legs), pulmonary embolism (blood clots migrating to the lungs), heart attack, stroke, and even death. Your overall health status going into surgery can increase your risk for certain medical complications. Your surgeon my require you to undergo a preoperative medical evaluation and clearance before surgery. This is very important because optimizing your medical status before surgery can minimize your risk for such complications.

Sexual function is often affected after cystectomy and is a major quality of life issue for both men and women under­going this procedure. In men, the vas deferens (the tubes that carry sperm from the testicles) are cut, resulting in infertility. Although infertility is not a major issue for most men undergoing cystectomy, you should discuss this with your urologist before surgery if you are planning to have children in the future. Because the nerves responsible for erection are located along the base of the prostate, erectile dysfunction is a common side effect after surgery. In high­ly selected cases, these nerves can be spared at the time of surgery, leading to improved potency outcomes. Erec­tile function after surgery depends on three main factors: age, preoperative function, and nerve sparing at the time of surgery.

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There are both short-term and long-term complications associated with urinary diversion. In the immediate post­operative period, urine can leak from the site where the ureters were sewn into the bowel. This is generally self- limiting and heals on its own several days to a week after surgery. Very rarely is any intervention required. If you do have a urine leak after surgery, your physician will likely monitor this by the output of your drains that were placed at the time of the operation. When the drain output decreases, this is a sign that the leak has healed.

The majority oflong-term complications patients experience after cystectomy are related to the urinary diversion. In fact, 10-20 percent of patients will need an additional procedure at some point over their lifetime to correct a problem with the urinary diversion. Over time, scar tissue can form at the site where the ureters were attached to the bowel, narrowing the lumen (cavity of the tube) that urine drains through. This is called a stricture. If a stricture occurs, it can inhibit the drainage of urine from the kidney, causing an obstruction. If this happens to you, you may feel pain in your back similar to that of a kidney stone, but some patients have no symptoms whatsoever if the stricture occurs slowly over time. Your physician will periodically evaluate your kidneys with CTs or ultrasound to ensure proper drainage. Treatment for anastomotic strictures involves opening up this narrowed area to its previous size to allow the normal flow of urine into the ileal conduit or urinary reservoir. This can often be accomplished endoscopically without intra-abdominal surgery, but if such conservative measures fail, open surgery with anastomotic revision may be warranted. Fortunately, anas­tomotic strictures only occur in 3-7 percent of patients, and open surgery for such strictures is even rarer.

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Actos Bladder Cancer 12/20/2011: The elderly, frail individuals with multiple coexisting chronic illnesses, individuals that are weakened through mahiutrition or who have compromised immunity all would face substantially increased risk of complications from standard chemotherapy regimens for bladder cancer. Unfortunately, cisplatin is toxic to kidneys, and many individuals with bladder cancer have compromised kidney function which effectively rules out the use of platinum based chemotherapy. Other treatment regimens exist and are being worked on for these individuals, but none show the efficacy of the standard therapy which includes cisplatin.

Most individuals treated with standard chemotherapy regimens with metastatic bladder cancer will have recurrence and progression of their disease. Multiple treatment regimens have been utilized with overall response rates of 10-40%.^[1] To date, regimens have generally used taxanes, both docetaxel and paclitaxel. Ifosfamide has been shown to have significant single agent activity as well, but is extremely toxic. Combination therapy with taxanes and ifosfamide are presently being tested.

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