HJNO Nov/Dec 2021

HEALTHCARE JOURNAL OF NEW ORLEANS I  NOV / DEC 2021 53 Jitendra Gandhi, MD Medical Oncology-Hematology Terrebonne Medical Center Treatment for Early- Stage, Cancer In-Situ In the early stage, in-situ (i.e., not inva- sive) bladder cancer can often be treat- ed with the instillation of BCG (Bacillus Calmette–Guérin), a local therapy, which stimulates the immune system locally to keep it under control. Usually, control can be achieved for years but needs frequent supervision with cystoscopy. About 30% may break through and become invasive and possibly life-threatening if not treated adequately, especially if there is noncompli- ance with regular follow-ups. Newer drugs are being developed for BCG failures but are not yet standard of care for front line, with one approved and many more soon to be permitted by the FDA. Treatments for Invasive Bladder Cancer Once bladder cancer becomes invasive, where it has invaded the muscle layer and is not yet metastatic, the best treatment re- mains total bladder removal, a cystectomy. Like a colostomy for colon cancer, this is a significant disruption of body image and a permanent life-changing procedure, though this is the only optimal option for a cure. Unfortunately, patients with bladder can- cer are elderly and often have coexisting conditions such as lung and heart disease, so they may not be good or safe surgical candidates. Preoperative chemotherapy is often given to improve chances, but this can also cause significant morbidity and, rarely, mortality. Chemotherapy and Other Systemic Treatments for Bladder Cancer The traditional chemotherapy goes by the acronymMVAC (methotrexate, vinblastine sulfate, doxorubicin hydrochloride [Adriam- ycin], and cisplatin) or modifiedMVAC. Both, while effective, can be quite toxic. Another option is platinum-gemcitabine, which is somewhat less toxic but has a risk for kidney damage. With bladder cancer, it should be noted that if there is an additional blockage to the kidneys, this could be risky. Immunology Drugs Just like BCG has been the anchor for in- situ cancer for decades, and it stimulates the immune system to control cancer, newer drugs are being approved for patients who either cannot tolerate surgery or are che- motherapy candidates. This could be, al- beit as of yet, a weaker but less toxic option. Studies are being conducted to see if they can replace chemotherapy, but data is early and, quite frankly, may never replace che- motherapy followed by surgery. Only time will tell, but I am very optimistic. Other New Drugs The FDAhas opened a tsunami of options within the last year. For patients with spe- cific mutations such as FGFR3, there are drugs targeted against it. For other rarer mu- tations, such as HER2NEU, there are existing drugs to target the cancer quite effectively. A new class of drugs, called “linker drugs,” is making tremendous headway and may be the most likely candidate to replace exist- ing treatments. These drugs are linked to a lethal drug explicitly targeted to the cancer cells, very much like a Trojan horse. The earliest one approved is erdafitinib — very effective with unique but manageable side effects. In combination with other drugs for metastatic cancer, a 92% response rate has been seen, with some even complete responses. Many other linkers are making their way to clinics. It may be too early to tell if this data can stick with more patients being accrued on the ongoing trials, so stay tuned. Another drug, sacituzumab, which is also approved for breast cancer, has been approved for metastatic bladder cancer, and it has significant activity. Radiation Often, this modality helps us control un- controllable bladder bleeding or in elderly patients who don’t have other options with or without chemotherapy. As discussed above, there are many op- tions for treatment, and the standard ap- proaches will soon completely change. In summary, it is best to decrease the risk for bladder cancer by not smoking, having frequent urine tests (i.e., once or twice a year), and staying healthy. Seek to get the best treatment options available, including chemotherapy and surgery, with blue light if available, and know significant hope is on the way for treatment and cure for this deadly disease, even in the advanced stages. This is not a comprehensive article, but numerous breakthroughs have happened in the last two years to help our patients cope with this dreaded disease, which un- fortunately can often be quickly fatal if un- controlled. n Jitendra G. Gandhi, MD, earned a medical degree at Seth G.S. Medical College, Bombay University in Bombay, India. He completed an internal medicine residency at Worcester City Hospital, in Worcester, Massachusetts,where he served as chief resident.He thenwent on to complete a fellowship in hematology/ oncology at the University of MassachusettsMedical Center.He is board certified in internal medicine and medical oncology. Gandhi has extensive oncology expertise participating in numerous clinical research studies as a principle investigator with various types of cancers.