The standard reasons for bladder removal for bladder cancer include: invasive bladder cancer that penetrates the bladder wall/muscle; bladder cancer that has yet to invade the muscle but has properties associated with a risk of invasion and does not respond to other less aggressive treatments; and recurrent bladder cancer that can not be adequately managed with techniques of removal through the urethra. Due to the lethality of invasive bladder cancer, bladder removal is virtually part of every treatment algorithm designed to cure invasive bladder cancer.

When a world class athlete or professional team sets major goals, they sit down with their coach and create a plan to achieve that goal. The coach sees the athlete for their highest potential and inspires them to begin to live that potential.

Together the athlete and the coach generate a training program to tap into existing gifts and talents and also build muscles in areas that require strengthening to achieve the goals.

When the athlete plateaus, hits a wall or momentarily loses confidence in themselves, the coach is there to support, encourage and remind the athlete who they REALLY are and what they are truly capable of.

Cancer Survivorship coaching is a revolutionary approach to working through the major challenges experienced when cancer touches your life. We define a clear picture of where you are stuck, stopped or blocked and what is holding you back from having the energy and ability to thrive.

How you view the experience can have a powerful effect on your energy level, outlook and your ability to harness the resources you need to heal and navigate the "new normal". You may not be able to change the circumstances of your cancer but you can shift how you choose to go through the experience.

For survivors who are newly diagnosed, coaching can help you overcome the sense of overwhelm and generate a plan to manage major decisions, build your support team and be empowered to take charge of your healing journey. It is also a great way to keep some balance.

It's not uncommon for the medical concerns to override all else and significantly impact quality of life and your primary relationships. Coaching helps identify potential pitfalls like this and supports you to design actions to generate a different outcome.

For post-treatment survivors, both those newly out of treatment and those years beyond who find themselves still dealing with after effects, coaching is a way to take your life back. It helps you build a bridge from where you are to where you want to be.

The experience of cancer often creates new priorities and goals for survivors. Sometimes this can leave you in a place of needing to redefine yourself. Coaching helps you to identify your core values, what you are truly committed to and how you want to invest your energy in alignment with that which matters most to you. When you do THAT you can't help but uncover a hidden source of energy and inspiration. You can read more about cancer survivorship coaching on my website athttp://www.cancersurvivorshipcoaching.com or on my guest post "You Have a Cancer What?!"athttp://bit.ly/g9gMnR. Of course, I'm happy to answer any further questions here on this site!

People transitioning from cancer patient to survivor need programs that speak to their physical, emotional, spiritual and social needs. I took advantage of counseling, rehabilatative exercise, support groups and stress reduction classes. Interestingly, survivors don't always know what programs they need because the transition is so overwhelming. That's why access to a patient navigator is crucial to their success. I know from my own experience how important my navigator was to my healing.

No drug is currently available for prevention of primary bladder cancer, although many agents are under clinical and preclinical evaluation. Approximately 80% bladder cancers are superficial at initial presentation (no invasion into the muscle), most of which will recur after surgical removal of the cancer. Current chemopreventive strategies are aimed at inhibiting the recurrence of superficial bladder cancer. BCG, mentioned before, which is an attenuated bacterium, is most commonly used in the clinic, but in patients BCG fails or is contraindicated, chemical agents (e.g. mitomycin) are used. All agents are delivered intravesically via a urethral catheter, which is intended to avoid or reduce systemic side effects of the drug. My lab has been working to develop oral agents that can be selectively delivered to bladder via urinary excretion, doing away with urethral catheter. Promising results have been obtained, but still in the preclinical stage. If anyone is interested in these studies, please read Bhattacharya et al., Inhibition of bladder cancer development by allylisothiocyanate, Carcinogenesis, 31, 281-286, 2010 or Bhattacharya et al., Allylisothiocyanate-rich mustard seed powder inhibits bladder cancer growth and muscle invasion, Carcinogenesis, 31, 2105-2110; 2010.

If bladder cancer is suspected, the next step is usually cystoscopy, an office procedure which allows the urologist to visually inspect the inside lining of the bladder. If a tumor is seen, the patient is scheduled for a trip to the operating room under anesthesia, during which the urologist will remove the tumor through a scope, sample the underlying bladder muscle to make sure there is no invasion, and administer a dose of anti-cancer medication into the bladder to mitigate the risk of recurrence. This may be followed with additional doses of the medication given over several weeks.

Minimally invasive surgery is always an option for any extirpative surgery, and bladder cancer (radical cystectomy) is no exception. However, the expertise of the surgeon is paramount since a positive margin (which can be more likely in minimally invasive surgery) can lead to death of the patient.

The large majority of bladder cancers are urothelial cell carcinomas. The aggressiveness of bladder cancer is determined by the stage and grade of the tumor. The grade is what the tumor looks like under the microscope and consists of low grade or high grade. This is from the 2004 International Society of Urologic Pathologists; however, some pathologists continue to use grades 1, 2 and 3. In general grade1 and 2 are low grade and grade 3 is considered high grade. The 2004 classification also introduced papillary neoplasia of low malignant potential. In addition to urothelial cell carcinoma are a number of histological variants that are thought to be more aggressive. These include micropapillary, small cell, glandular differentiation, squamous, sarcomatoid, lymphoepitheloid as well as a few others.

Stage is the depth of penetration of the bladder cancer. There are 2 main categories i.e. non muscle invasive (NMIBC) and muscle invasive bladder cancer. Low grade NMIBC has a recurrence rate of approximately 50% but at most 2-4% risk of progression. High grade NMIBC such as Ta, T1 and carcinoma in-situ have a slightly higher risk of recurrence with approximately 30-40% risk of progression. A number of risk stratifications for NMIBC have been developed taking into account grade, stage, number and size of tumors as well as number of recurrences to classify patients as having low, intermediate and high risk of tumor recurrence and progression. Muscle invasive bladder cancer is always high grade and is associated with microscopic metastatic disease in up to 50% of patients at the time of diagnosis. To date there are no consistent molecular or genetic markers that are able to accurately stratify patients. Pathologic staging i.e. presence of extravesical invasion, involvement of adjacent organs such as the prostate or vagina or lymph node involvement are all associated with a poor prognosis. The Cancer Genome Atlas (TCGA) project will aid in the identification of prognostic biomarkers for bladder cancer.

If one interprets the findings from the Grossman study (neoadjuvant chemotherapy for invasive bladder cancer) from 2003 NEJM, all patients with muscle invasive bladder cancer, eligible for cisplatin should be offered neoadjuvant therapy. This is a simplified answer for another complex question. Obviously age, comorbid factors come to play including renal function.

All patients undergoing radical cystectomy for bladder cancer should have a pelvic lymph node dissection. We are currently participating in a National Cancer Institute sponsored intergroup randomized study through the Southwest Oncology Group (SWOG) comparing an extended versus standard pelvic lymph node dissection for patients with invasive bladder cancer. The hypothesis being studied is whether a more extensive lymph node dissection will lead to improved bladder cancer survival.

Thanks for asking, Debbie! As with everything, we take it one day at a time around here. My son, Zach, was 3 1/2 when I was diagnosed. Explaining the complexity of cancer to a child that age (even a very articulate one) is a daunting task. We have always chosen to be upfront. We share what we THINK is the right amount of information in a way that is clear but not demeaning, and then we answer all of his questions. We did then, and continue to do so now.

As for how HE does with it...even after all this time there are good days and bad. Most of the time he is as committed to fighting this battle as I am. He eagerly sends me off to conferences and peer review meetings, despite missing me. He gives up "our" time to let me (even help me) blog, and is part of my blog management team, writing, approving posts and researching some of the decisions I have to make for me.

Other days he hates it. He understands that after cancer we chose not to risk another pregnancy, and he still yearns for a sibling. I'm sure he quietly struggles with the time it take from us as well, though he never says it. And I think he'd be just as happy if he didn't have to CARE about all the pink in the markets come October. The level of "awareness" with which we live after cancer can be exhausting for a child.

All in all, I believe that when someone is diagnosed with cancer, it is like a ripple in a pond. It cannot help but impact everyone around them...and the closer one is to the source of the initial disturbance, the more wholly the impact on their life. He's my son; of course I think he is remarkable. But I also know that this experience has changed the course of his life forever. At a very young age, he has learned to see the world through the eyes of another, he has embraced compassion in a way that I find deeply moving, and he knows it is his task to make a difference in the world. How this has shaped him is yet another of cancer's silver linings...