How comm is radiation treatments end up causing bladder cancer?
Anybody here has had experience with bladder cancer (caused by radiation treatments)?
Pease share your experience or point to where to research this issue?
Also, recommendation for bladder cancer specialists in Southern California.
Thx,
Akai
It's very rare - about 2 in 1000 men have a bladder cancer due to prostate radiation. Sometimes men are more prone to both.
prostatecancer.news/2016/08...
Yes. But some need to be a bit more careful. I was Dx’d at Dana Farber, after in-depth genetic counseling, with Li-Fraumeni Syndrome. Essentially a propensity for cancers. So far (lucky me!) I have wracked up Prostate Cancer (Surgery, now recurrent), Chondrosarcoma (surgery), and Liposarcoma (surgery), and recurrent Liposarcoma (yet more surgery!) My DFCI MO wants to chat about SBRT for the recurrent PCa, but obviously it will need to be a longer conversation in my case.
In this study they found a risk of 2% for bladder cancer five years after salvage radiation:
redjournal.org/article/S036...
Here is the chart showing this:
It's certainly a peculiar study. Why do you suppose that the risk of secondary cancer was cut in half if they received salvage radiation? In men who have failed RP, the radiation cured the secondary cancer that may already be there or prevented it.
Other, larger RCTs show very different results. Zaorsky et al looked at all RCTs.
sciencedirect.com/science/a...
"Randomized controlled trials (RCTs) and pooled meta-analyses have not demonstrated a measurable increased risk of secondary cancers; many actually show numerically lower rates even without an identifiable “trend.” Of 6884 PCa patients from 12 RCTs with enrollment started after 1990, there were almost no patients reported to have died from secondary cancers."
ncbi.nlm.nih.gov/pmc/articl...
"In the ProtecT RCT that randomized 1643 patients with localized PCa to active monitoring, RP, or RT, less than 5% of patients in each group died from a neoplasm other than PCa (22, 25, and 23 patients, respectively)."
nejm.org/doi/pdf/10.1056/NE...
"In the EORTC trial , which randomized 1005 men to observation or adjuvant RT, second cancers occurred in 69 patients in the observation arm (13.7%) and 68 in the adjuvant RT arm (13.5%). "
nejm.org/doi/full/10.1056/n...
"Wiltink et al. pooled three RCTs of rectal and endometrial cancer patients (n = 2,554 total) treated with surgery with or without RT and showed no significant difference in the development of secondary cancers in RT-treated patients."
pubmed.ncbi.nlm.nih.gov/255...
This randomized, controlled trial was presented at ASCO in 2019 and then published peer-reviewed in a respected magazine. I just accept the published results.
Yes, but it contradicts itself. I accept the results of larger RCTs on thousands of patients over it, don't you?
Why do you suppose that the risk of secondary cancer was cut in half if they received salvage radiation? In men who have failed RP, the radiation cured the secondary cancer that may already be there or prevented it.
In the trial, secondary cancers (SC) were defined as non-prostate cancers, These were colon, lung, bladder and rectal cancer. The trial tried to determine if patients who got radiated had a higher risk to develop non-prostate cancers. For that they compared ADT alone (ET) and ADT plus radiation (ET+RT). They found that the ADT plus radiation group had a higher risk for non-prostate cancers. This indicates that radiation increases the risk for secondary cancers. This is not a new finding, when I get radiated I have to sign a sheet stating that I am aware that radiation causes a risk for secondary cancers.
From the study: "With a median follow up of 12·2 years for all patients, we found a total of 293 second cancers, 125 cases in the ET group and 168 cases in the ET+RT group (Figure 1). The most common second cancer was colon cancer (n=47) followed by lung cancer (n=43). There were 31 cases of urinary bladder cancer and 19 cases of rectal cancer"
The image I posted shows the ADT group as the black line and the ADT+RT group as the red line. So without RT the risk for bladder cancer at 5 years was about zero% and with RT it was about 2%. The difference should not stop anybody to get salvage radiation I think.
I accept the results of larger RCTs on thousands of patients over it, don't you?
Well, I observe you frequently refer to trials with fewer patients in your blog. If you just accept RCTs with thousands of patients, you can only accept therapies offered by big pharma who can afford these big trials. These therapies often demonstrate an overall survival of three months only and the drugs cost an incredible amount of money to provide that benefit.
There will never be RCTs with thousands of patients for surgical techniques, radiation procedures, PET/CTs, or generic drugs and drugs currently used off-label. Big pharma cannot make enough money with these therapies to finance big trials for these. The Choline PET/CT was developed in the US but mostly used outside the US. Same seems to happen with the PSMA PET/CT. Big pharma has no interest in financing a big RCT for that so it will not be available in the US, apart from the two sites which got it approved now. If there would be no STAMPEDE trial in the UK we would never learn whether estrogen patches or Metformin pills work against PCa. Big pharma has no interest in that. Also metastases directed therapy, I will have died a long time ago until a big RCT finally shows or doesn't show a survival benefit for this therapy. If you have to make a decision right now and no phase III trial results are available, you have to base your decision on trials with fewer patients.
I understand that big pharma is only interested in new drugs but I think there should be a simple way for other therapies to become approved as well. I think this would be beneficial for the patients and the researchers too.
Zaorsky didn't rely on "Big Pharma," he did a meta-analysis of smaller studies. You pulled out one peculiar little study and held it up as dispositive. A mistake, I think.
I have no idea why you are engaging in a diatribe against large studies, including those financed by large drug companies. It has nothing to do with the topic, it's just a rant, I guess. If there is a larger, higher level of evidence study, it is certainly more definitive than a smaller, lower level of evidence study. Who in his right mind thinks otherwise?
"There will never be RCTs with thousands of patients for surgical techniques, radiation procedures," Like this one, for example?
Why do you believe the scandinavian study is "peculiar"? They did find a statistically significant and more than doubled risk of urinary bladder cancer in the HT+RT arm compared to the HT only arm. They confirmed a survival benefit in the HT+RT arm, the secondary cancer disadvantage is by far outweighed by the OS benefit of RT! (Also, there is no RP patients in the study, salvage radiation was in the HT arm)
It is peculiar because it suggests that primary radiation doubled the incidence of bladder cancer, but salvage radiation cut it in half. Does radiation increase the incidence of secondary cancer or reduce it? Studies have to be consistent and plausible to suggest causation. When results are so inconsistent, it is peculiar. And why look to that peculiar little study when we have so many larger RCTs to rely upon, as shown by Zaorsky's meta-analysis of RCTs?
Yes, that looks peculiar and the authors explanation is that the salvage group was a very small, and healthier, subgroup with a long time (6 years) until their RT, i.e. the follow up time for that group is shorter.
The overall long follow up time, 10-20 years, makes the study interesting, I think, despite the fact that the number of participants was not so large.
There are much larger RCTs, like ProtecT, that have run for 10 years. A few that Zaorsky looked at had 10 year data. I agree that 20-year data would be nice. But the problem one runs into with the longer-f/u trials is that they become irrelevant. In the 1990s, IGRT/IMRT wasn't used, so radiation to organs at risk was unable to meet dose constraints that are widely used now.
"Absolute differences in risk of bladder cancer between patients exposed and unexposed to radiotherapy ranged from 0 to 0.6 cancers per 100 patients, "bmj.com/content/352/bmj.i851
Looks like the risk of RT is low and the benefit outweighed the risk per studies.
I may be one of the unlucky ones.
Diagnosed at G6 in 2012, but G9 in 2017.
Had HDRBT and EBRT in 2017 plus Zytiga and Eligard till 2019.
Had blood clots and some blood in urine in October of 2018.
Developed urinary stricture, complete blockage in March of 2019. Had a urethrotomy to open up the urethra.
Had blood in urine in June of 2020 but blood disappeared in a week, my urologist tried cystoscopy but discovered that the stricture is back and unable to pass the scope to inspect the bladder.
The urethra has narrowed again but I can still urinate without trouble.
Last week started having blood in urine for couple of days, then disappeared.
Yesterday blood in urine again, bad sign for bladder cancer.
Problem is if cystoscope can’t pass through the urethra then not many if any alternative left to diagnose the bladder cancer.
Will have to Try to consult with other urologists for alternative diagnoses other than cystoscopy thais is why I am seeking advices.
I am in SoCal.
Akai
So, did the biopsy the bladder?
I had a cystostomy or an abdominal catheter because I had a stricture in the urethra. It does not hurt and the wound heals again quickly when the catheter is removed. Surprisingly simple procedure.
Nope, no biopsy of the bladder. Will be looking for a urologist specializing in bladder cancer, perhaps at City of Hope. It’s a bit hard to choose which urologist as they don’t always identify their specialty on their website.
My urologist at USC said the cystoscope is 16French in diameter and my urethra is now at 8 French and he could not pass the scope through. The scope went in to as far as the start of the narrowing part. I actually saw two other urologists regarding my stricture, one at UCLA who estimated my stricture at 12 French, and another specialist at UC Irvine who did not give my an estimate.
They (reconstructive urologists) all wanted to do a urethroplasty which is a major operation. Mine was supposedly caused by the RTs. I have been delaying it because I am still able to urinate. When it first happened in 2019 I didn't even know that I had a stricture or what it was, I went into an ER while I was on vacation, complete blockage, unable to void, a very scary situation. They did a urethrotomy on an emergency basis with local anesthesia. But urethrotomy is not a permanent cure, recurrence rate is 100%, ranging from eight months to 4 years. I learned all this after the procedure. Very painful procedure, the whole experience was dreadful. I am considering a urethroplasty which is a major surgery but may provide a permanent cure. Unfortunately, tissue damaged by radiation may not heal as well as normal tissue, and the long term success rate for RT damaged stricture is not as high as normal tissue.
Definitely a rock and a hard place. Now may be facing bladder cancer issue in addition to my PCa.
I don't understand how they estimated the size of the opening jut visually when the scope stopped? I had one urologist who could get a scope in no matter what. He said that was because he was older and tougher than the young guys. The last time the new urologist was about to give up. I had been exercising my urethra with occasional self caths and at that time I could urinate weakly but could get in both a 14 and 16 FR. I suggested that he let me try and then he got it in. My stricture is quite long and can be a problem at some times and not at others.
You might want to try self cathing with a 12 and then a 14 and a 16 over time. Unfortunately it is bitch to get a variety of catheters prescribed. I have a good collection including some I bought on E-Bay. Also bought some of the silicone "sounds" that are supposed to be fun? Also a tapered tip catheter might go in more easily and allow you to exercise with a larger cath. My old urologist also once rammed a dilator into me when I was nearly blocked. When I screamed in pain he said he did not tell me how painful it would be or I would not have consented. I can give you his name if you want 
Not sure how they estimated my urethral stricture. However, on a different note, there is a new FDA approved for treating anterior stricture of 3cm or shorter called Optilume. Its a DCB (drug coated balloon), coated with Paclitaxel. I am looking into it, my stricture is at membranous, this may not work for me. Also, want to know if Paclitaxel is harmful to prostate cancer. It is so new that few urologists have used it.
It’s worth investigating. Check out YouTube for more information.
Also forgot to mention this. I think you can search the archives as I have posted about it a few times. Castor oil hot packs can soften scar tissue possibly making your urethra more flexible and catheter friendly. I had a stricture right at my bladder neck that often was impassible by even a tieman tip cath. A week of hot pcaks had me peeing again.
Thanks. It’s been three years since my DVIU and I will have to deal with it soon, just trying to avoid urethroplasty if possible.
I'm so sorry.
They should have made a cystostomy or an abdominal catheter in the ER and have you decide on the urethrotomy later. Of cause the urethrotomy generates a higher bill.
As I said above, a cystostomy or an abdominal catheter will allow to diagnose the bladder cancer. If it is a non- muscle-invasive bladder cancer it can be cured without a lot of effort.
I had two urethrotomies with general anesthetic. It was painful but not very painful. The recurrence rate is assumed to be about 30% and not 100% as far as I know. So I would get a second urethrotomy done now and this will allow to address the bladder cancer afterwards or at the same time of the urethrotomy.
For urethroplasty they take tissue from your mouth. This results in a scar which often no longer allows you to open your mouth fully and can even cause permanent pain. It can also cause trouble with your teeth in the long run because you cannot open your mouth as before. Finally, I was told by an excellent doctor that you can do the urethroplasty only for short strictures and the area where the urethra passes through the prostate is a problematic area for this. So the urethroplasty may even fail in your case and all you gain is problems in your mouth.
There is no good solution for this problem. Try another urethotomy first. Instead of urethroplasty I would prefer to live with an abdominal catheter and avoid extensive surgery causing many side effects.
Thanks GP24, I think I was off when I quoted 100% recurrence rate, its the article below that I looked at after I had the DVIU.ncbi.nlm.nih.gov/pmc/articl...
How far apart were the two DVIUs that you had?
My stricture is short, about 1cm which is an excellent candidate for urethroplasty without grafting. I had both retrograde urethrography (RUG), and voiding cystourethrography (VCUG) done by a specialist at UC Irvine.
They all said I have a good chance of a successful urethroplasty but none of them have had much experience with the RT induced strictures.
I will be looking for a urologist to consult on the hematuria issue tomorrow. Perhaps there is a test that can be performed without cystoscopy in the meantime.
My estimate for recurrence was based on what doctors told me and the rates are apparently higher than what they said.
Before I had my last TURP I discussed with doctors if I should get another TURP or urethroplasty. I was told that I had a good chance that the TURP will work for a long time and therefore I should do that instead of urethroplasty. As this study writes:
"Although the success of urethrotomy at 5 years is less than that of urethroplasty 50% compared to 83% in 1 study. The ease and safety of urethrotomy make it the procedure of first choice for the treatment of male urethral strictures."
sciencedirect.com/science/a...
Urethroplasty also has a recurrence rate which is between 26% and 31% according to this study:
onlinelibrary.wiley.com/doi...
My first urethrotomy worked for almost four years, however, I waited until my urethra was almost completely blocked. Then I went to the hospital, got an abdominal catheter there and was asked to make an appointment to discuss what to do next. I visited several doctors to discuss that.
The doctor who did the second TURP specialises in salvage surgery for recurrences after radiation. He recommended to do a anastomosis next. So he would cut out the stricture and tie both ends of the urethra together just as its done in a standard prostate surgery. Salvage surgery has a higher risk of side effects than primary prostate surgery, though.
As I said, in your case I would get a second urethrotomy which will allow for a cystoscopy of the bladder. Depending on how invasive the bladder cancer is, this could influence how to treat the stricture of the urethra.
I have bladder cancer that developed about 2 years ago. I am used to blood and blood clots in urine but it wouldn’t stop. After a month I had a cystoscopy and it was discovered. Every 3 months I have to have a cystoscopy to clean out anything the urologist sees. It has been attributed to the radiation, but who knows?
My best friend died a year ago from bladder cancer, 10 years after receiving radioactive seeds for his prostate cancer. He was convinced there was a connection.
I am not sure if this means anything but I had read it a while ago:
“Cxbladder is a suite of non-invasive, simple to use bladder cancer detection tests that measure unique molecular signatures to help rule out, or diagnose bladder cancer.”
Thanks Ahk1, I did call them this morning following an email exchange with another member who had it done. The good news is, according to the lady I spoke to, Medicare is now covering the cost of the test.
GP24, I am exploring CXbladder Test as an alternative to cystoscopy. Trying to get an appointment with the urologist who has ordered this test in the past. At this point I do not know if I do or do not have bladder cancer.
Let us all pray that akaipop3ps does NOT have bladder cancer...
Good Luck, Good Health and Good Humor.
j-o-h-n Monday 01/18/2021 8:01 PM EST
Amen!
Thank you John.
bladder radiation burns
HBOT for bladder radiation cystitis
Long term side effects from salvage radiation after radical prostatectomy 
Ureter Restriction from Radiation Treatments?
Radiation
