- In Mexico, bladder cancer is considered the fourth most common type of cancer among men and mainly affects people over 55 years of age.
- One of the problems with the tumor is that its symptoms are not very specific, which is why they are often confused with sexually transmitted diseases or urinary tract infections, which can delay diagnosis.
- The main risk factors are chemical exposure, smoking, alcohol consumption, recurrent bladder infections and age.
Among the subtypes that make up the bladder cancer there is a fairly common one and it is urothelial carcinoma because it represents 90% of cases. It originates from cells of the same name located in the urinary tract. The survival rate is, on average, 77%, depending largely on whether or not it has spread outside the inner layer of the bladder wall.
In the past, this particularity forced perform invasive treatments to increase the chances of recovery. On the other hand, today, thanks to medical advances, it is possible to count on treatments that do not require surgery, as long as the patient is eligible.
Treatment options for urothelial cancer they have historically been at two ends of a spectrum: laser or cautery for a small, low-grade tumor or radical nephroureterectomy.
These options may not be ideal for a subgroup of patients with compromised renal function and low-grade upper tract urothelial cancer.
For his part, Massachusetts General Hospital is one of the few medical centers offering a novel, minimally invasive treatment to a subgroup of adult patients with low-grade upper tract urothelial cancer (LG-UTUC). Treatment with a mitomycin gel is a chemoablative method that treats cancer and may prevent the need for radical nephroureterectomy.
“This is a new option for patients in whom the presence of LG-UTUC and a sufficient tumor volume that we cannot treat with laser or cautery have been demonstrated by biopsy. That group of patients previously had no other option than nephroureterectomy, but now we have another option for them,” says Adam S. Feldman, a urologic oncologist in the Department of Urology at Massachusetts General Hospital.
Selection of appropriate cases of urothelial cancer
Brian Eisner, medical director of the Department of Urology at Mass General and chief of the Urology Service at Newton-Wellesley Hospital, stresses the Importance of patient selection for mitomycin gel.
“The ideal candidate for this treatment is a person with low-volume, low-grade, non-invasive UTUC. It may also be useful in patients with high-volume, low-grade UTUC who have poor renal function, or in the compassionate or palliative treatment of patients with high-grade UTUC who also have a solitary kidney. But the strongest indication for this treatment is low-volume, low-grade UTUC.”
Mitomycin gel is effective for chemoablation and decreases the risk of recurrence in patients with low-grade UTUC, as demonstrated by the OLYMPUS trial, the study of which was published in The Lancet Oncology.
Patients must be carefully evaluated by a multidisciplinary oncology and urology team, using biopsy and imaging such as a CT or MRI.
“We take everything into account: the age of the patient, their general state of health, the risk of suffering, whether we offer them standard kidney removal, and what we think the prognosis would be if we offer this less invasive kidney-sparing treatment. It’s up to the surgeons to say, ‘You’re a great candidate for this,’ or ‘you’re not.’
Endoscopic administration of mitomycin
Mitomycin gel, known commercially as Jelmyto, is administered in six induction doses plus 11 maintenance doses via an outpatient endoscopic procedure.
“First we perform a cystoscopy to see inside the bladder, then we pass a catheter up to the kidney and instill the mitomycin. Mitomycin is presented as a gel that slowly dissolves over four to six hours and travels down the renal pelvis. It travels down the ureter to the bladder and is then excreted. It’s actually topical chemotherapy, so it doesn’t have the same side effects as systemic therapy, like hair loss.”
According to him OLYMPUS trialthe most common side effects are ureteral stricture (44%), urinary infection (32%), hematuria (31%), flank pain (30%), and nausea (24%).
Apply extensive experience to new approaches
Mass General is well positioned to become one of the few hospitals to offer mitomycin gel, given the institutional experience in similar conditions.
Urologists are now working to introduce mitomycin gel to patients with LG-UTUC, and perhaps eventually include other patient populations.
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