Maggie McKay (Host): Bladder cancer can sound like a concerning diagnosis, but it does have a relatively high survival rate if it hasn't spread beyond the inner layer of the bladder wall. Our guest today is Dr. Ryan Werntz, Prisma Health urologic oncologist. He's going to fill us in on the latest information on bladder cancer.

Host: This is Flourish, a podcast from Prisma Health. I'm your host, Maggie McKay. Thank you so much for being here, Dr. Werntz. Would you please introduce yourself?

Dr Ryan Werntz: Yeah. So, my name's Ryan Werntz. I'm a urologic oncologist here at Prisma Health. I run an advanced pelvic and retroperitoneal malignancy center where we focus on diseases of the retroperitoneum and the pelvis, and these can be multidisciplinary in nature. I also run a urologic oncology fellowship here that's a one-year program where folks from around the country who have had formal training in urology can train to be urologic oncologists.

Host: Sounds like you are busy. So just to start off, what are the symptoms of bladder cancer?

Dr Ryan Werntz: Yeah. The most common symptom is blood in the urine. We call that hematuria. And it can be in the form of what we call gross hematuria, where the patient themselves actually visibly see blood, or it can be in the form of what we call microscopic hematuria, where your general practitioner will pick up blood in the urine on a test, a urine-based test. Additionally, women can sometimes present with recurrent urinary tract infections.

Host: And what causes bladder cancer?

Dr Ryan Werntz: The most common cause typically is smoking. Around 50% of patients with a history of bladder cancer actually have also a history of a significant pack year.

Host: Are there hereditary factors?

Dr Ryan Werntz: There can be hereditary factors. The other factors can be workplace. Some patients have a history where they work with dyes and other environmental factors. And the rationale behind both smoking and environmental is a lot of these toxins are filtered by your blood and your kidneys filter your blood and they concentrate the toxins into your urinary tract, and your bladder stores urines. So when you have prolonged time along the urothelium and the lining of the bladder, the thought is this causes change over time.

Host: Wow. Who knew that where you work could affect your organs? Does diet contribute to bladder cancer?

Dr Ryan Werntz: We don't have any strong evidence for that. There's a variety of different things. I mean, in Africa, the most common histology is not really urothelial cancer, which is the typical cancer you get in the United States and other developed countries. But it's squamous cell cancer, which is caused by actually a parasite. So, I mean, there's a variety of factors, but diet is not one of those.

Host: Dr. Werntz, is bladder cancer a fast-spreading cancer?

Dr Ryan Werntz: There's a big spectrum of what we call bladder cancer, which is really urothelial cancer. It just depends on the grade and stage of the tumors. And there can be low-grade bladder cancer where the individual cells kind of mimic what our normal bladder does. And these are typically cancers that do not spread, that do not progress into the wall of the bladder. And these are not that concerning to be honest. But they do recur, so you have to watch them. Whereas high-grade bladder cancer, these are high-grade cells, these are quite aggressive, and these could spread into the wall and they can spread to other sites of your body and we call that metastasis.

Host: How is bladder cancer treated? Can it be cured?

Dr Ryan Werntz: Yeah. So, low-grade bladder cancer typically is treated what we call endoscopically. So just with scopes, sometimes we use chemotherapy washes in the bladder. High-grade bladder cancer, we break this down into two different types, one we call muscle-invasive bladder cancer, and the other we call non-muscle-invasive bladder cancer.

And in patients with high-grade, non-muscle-invasive bladder cancer, we actually try to treat these with what we call a TURBT, which is where you put a scope in the bladder, and you remove the tumors with a scope. And then you treat those patients with what we call BCG, and this is actually a form of tuberculosis. This was the first form of immunotherapy, and you put this in the bladder and that causes your own immune system to attack the cancer cells, okay?

So, those are non-muscle-invasive patients. In patients with muscle-invasive bladder cancer, these are lethal cancers. And if left untreated, muscle-invasive bladder cancer usually leads to metastasis and death within a year. So, these patients are treated quite aggressively and we treat these patients with oftentimes chemotherapy upfront, followed by bladder removal, or potentially in some certain, instances we can do radiation and keep the bladder intact.

Host: If your bladder's removed, how does that work?

Dr Ryan Werntz: If your bladder is removed, you have to divert the urine somewhere. So, your kidneys produce urine and they flow down tubes called the ureters. So when you remove the bladder, you have to reconnect the ureters. So, there's a couple different ways to do this. The most common way is you take a small piece of the small intestine and you plug the ureters into that and you bring it to the skin. And they wear an appliance on their abdomen called an ostomy bag.

Another way, and this is what we specialize in here, is we build patients new bladders out of their intestine and we connect it back to their urethra, so that they can urinate through their urethra, okay? And the third option is something called an Indiana pouch. And this is where if patients do not have a viable urethra, but they do not want to wear a bag, you build them a urinary reservoir on the inside and they actually catheterize through their abdomen.

Host: Wow, that is all amazing. So, you mentioned earlier about smoking and bladder cancer. Can people who don't smoke get it?

Dr Ryan Werntz: Yeah. People who don't smoke can get it. And you see this often in patients that have chronic inflammation of the bladder. So for example, patients with chronic catheters, this can cause inflammation over time and it can cause change in the bladder and they can get it. So, that's probably the most common scenario. You can actually see it in patients with a prior history of pelvic radiation. Those patients can also get bladder cancer.

Host: Can an ultrasound detect bladder cancer?

Dr Ryan Werntz: It's pretty rare. So, you know, the bladder's kind of a unique structure in that it's not a solid organ like our kidney and our liver. it's an organ that's hollow. So, the ultrasound can see large bladder tumors, but it cannot see smaller bladder tumors. Really, the best way to be evaluated if you see blood in your urine is you get a CAT scan and even sometimes that does not find bladder tumors. You actually have to put a scope in the bladder and directly visualize the bladder tumor.

Host: How common is bladder cancer?

Dr Ryan Werntz: That's a loaded question. It's not as common as something like prostate cancer, which is the most common solid organ malignancy in men. And it's not as rare as some cancers like sarcoma. But it's common in urology, I would say.

Host: Thank you so much for being here and filling us in on bladder cancer and what we need to know. It was so educational. I didn't know most of that, so thank you.

Dr Ryan Werntz: Thank you. Thank you for having me.

Maggie McKay (Host): Again, that's Dr. Ryan Werntz. To find out more, go to prismahealth.org/flourish. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. This has been Flourish, a podcast from Prisma Health.