November 8, 2011. Today was the day of the CT Scan and the Cystoscopy. These tests are to see if the eleven chemo therapies (Cisplatin, Gemcitabine and Carboplatin) that I had over the past weeks had a positive affect on the cancer in my bladder, the invaded muscle parts at the top of the bladder and on the affected lymph nodes around the bladder in the pelvis area. The positive affect had to be that the tumor in my bladder was still no longer visible and that the invasive cancer came to a still stand and that the affected lymph nodes would have shrunk. I would be informed about the outcome of these tests by the internist on November 16th, 2011. The days before these tests I felt “activity” in my stomach/pelvis area which was explained by the doctors/lawyers (I believe strongly that doctors, besides their studies medicine, also are being trained to be a qualified lawyer. I base this on my experience given the answers to the questions you put to doctors re your condition…) that this could be positive activity meaning that the cancer was diminishing or, to the negative (which I always intend to believe to be the case), that the cancer was extending its activity. So, a hard time waiting until the 16th to hear from the internist what re my present condition. The help desk told me upon arrival at the hospital that I could have my “lost” chemo therapy that I missed last week situation today if I wanted if my condition was OK. I missed the last chemo (this case Gemcitabine) because my condition appeared not to be OK and my blood sample showed a very low white blood cell count. So I had a new blood sample taken for the purpose of having the last chemo to complete the program of 12 chemo sessions. After this I went to have the CT Scan. The drill is here that you start drinking a liter of water containing a contrast substance the day before you visit the hospital to have the CT Scan. At the hospital, when you are positioned on a bed in front of the CT Scan, they place an IV in your arm so that they can inject you with another contrast substance (iodine) moments before they roll you in the CT Scan and take the required pictures. Contrast helps certain areas show up better on the x-rays. (See below for a complete description of what a CT Scan is all about). After the CT Scan I had to wait for an hour for the blood sample test results. My white blood cell count was OK again and I was planned for another hour later to have the the last chemo in this treatment program. I had about 5 nurses that tried to put the IV in a vein in one of my arms before being successful. This is a somewhat painful exercise. They always rinse your system (kidneys) with a saline (NaCl) solution prior to the chemo.  Saline solution for intravenous infusion. The white port at the base of the bag is where additives can be injected with a hypodermic needle. The port with the blue cover is where the bag is spiked with an infusion set. The chemo is given in a room with a number of beds and large chairs where other people also receive their chemo treatment simultaneously with you and provide you, wanted or not, with their demotivating experience in battling their cancer. Two nurses have to check and sign the documents that will release the chemo that will be given to you. They ask your day of birth and both check if you are the right patient given the right chemo. The chemo is made in the hospital’s pharmacy to your particular condition, body size etc. See below for details of this chemo therapy. The days following the chemo I feel sick, nausea (for which you get medications that give you other pains such as headaches) and your white blood cell count drops again at this final stage of the chemo treatment program. Your overall condition gets to the lowest point possible with your heart pumping overtime. The two stairs that I have to make in my house to get to my bed feel like having had a football game, arriving totally breathless.

Cystoscopy

After the chemo I still had to undergo the Cystoscopy which I consider the worse section of this day’s treatment session because of my bad experiences with catheters in general and that they had pushed up to the penis during earlier operations. This is not my general idea of having a good time. After the two tumor removal operations from the bladder that I had earlier I am also very sensitive in the general internal area of the bladder. Basically the mucous layers of the bladder after the tumor removals are still very soft and possibly open. Hence, I will have therefore my Cystoscopy under anesthesia if only for the reason that my manhood is also diminished with the presence of nurses that can view you in your most unprestigous condition and there is nothing you can do about it. So I “go under” so that I do not have to see faces. The Cystoscopy is done to see if their are any indications of the cancer developing new activity. It is also possible that the urologist takes a biopsy, with a special biopsy catheter, at the same time. The hospital uses the latest equipment for this, I hope because I do not look, flexible sterile telescoping and equipment, very fine tubing etc. If you see someone coming with a rigid Cystoscope that looks like an iron bar, RUN, do not wait and do not look, or go, back anymore…. You are then clearly in the wrong place. It is almost certain that you will have a bladder infection after a Cystoscopy. I try to prevent taking antibiotics to overcome bladder infections. Instead I use a natural product called D-mannose. I take two tablets of D-manose the evening before the Cystoscopy and six tablets (spread over the day) the day after the Cystoscopy. This is a kind of preventive treatment that also helps me when I repeat this exercise say once per month to maintain a healthy bladder without the possible side effects of antibiotics. After the Cystoscopy urinating is a little painful but also here the D-mannose helps to keep that pain down because it prevents infection. Also the bladder may feel a little painful after the Cystoscopy possibly because of a biopsy taken or the end of the Cystoscope having touched the internal layers of the bladder.

See below for Cancer of the Bladder Diagnosis

Important!: With chemos and cystoscopy’s drink as much liquids, water, as you can. The liquids taken will restore kidney functions, keep the bladder clean and prevents infections of the bladder. A clear indication that you drink sufficient liquids is that your urine has changed from the typical yellow color to a much lighter color.

CT scan

How the Test is Performed

You will be asked to lie on a narrow table that slides into the center of the CT scanner.

Once you are inside the scanner, the machine’s x-ray beam rotates around you. (Modern “spiral” scanners can perform the exam without stopping.)

A computer creates separate images of the body area, called slices. These images can be stored, viewed on a monitor, or printed on film. Three-dimensional models of the body area can be created by stacking the slices together.

You must be still during the exam, because movement causes blurred images. You may be told to hold your breath for short periods of time.

Generally, complete scans take only a few minutes. The newest scanners can image your entire body, head to toe, in less than 30 seconds.

How to Prepare for the Test

Certain exams require a special dye, called contrast, to be delivered into the body before the test starts. Contrast helps certain areas show up better on the x-rays.

Let your doctor know if you have ever had a reaction to contrast. You may need to take medications before the test in order to safely receive this substance.

Contrast can be given several ways, and depends on the type of CT being performed.

• It may be delivered through a vein (IV) in your hand or forearm.
• It may be given through the rectum using an enema.
• You might drink the contrast before your scan. When you actually drink the contrast depends on the type of exam being done. The contrast liquid may taste chalky, although some are flavored to make it taste a little better. The contrast eventually passes out of your body through your stools.

If contrast is used, you may also be asked not to eat or drink anything for 4-6 hours before the test.

Before receiving the contrast, tell your health care provider if you take the diabetes medication metformin (Glucophage) because you may need to take extra precautions.

If you weigh more than 300 pounds, find out if the CT machine has a weight limit. Too much weight can cause damage to the scanner’s working parts.

You will be asked to remove jewelry and wear a hospital gown during the study.

How the Test Will Feel

Some people may have discomfort from lying on the hard table.

Contrast given through an IV may cause a slight burning sensation, a metallic taste in the mouth, and a warm flushing of the body. These sensations are normal and usually go away within a few seconds.

Why the Test is Performed

CT rapidly creates detailed pictures of the body, including the brain, chest, spine, and abdomen. The test may be used to:

• Diagnose an infection
• Guide a surgeon to the right area during a biopsy
• Identify masses and tumors, including cancer
• Study blood vessels

Normal Results

Results are considered normal if the organs and structures being examined are normal in appearance.

What Abnormal Results Mean

Abnormal results depend on the part of the body being studied. Talk to your health care provider with any questions and concerns.

Risks

Risks of CT scans include:

• Being exposed to radiation
• Allergic reaction to contrast dye

CT scans do expose you to more radiation than regular x-rays. Having many x-rays or CT scans over time may increase your risk for cancer. However, the risk from any one scan is small. You and your doctor should weigh this risk against the benefits of getting a correct diagnosis for a medical problem.

Some people have allergies to contrast dye. Let your doctor know if you have ever had an allergic reaction to injected contrast dye.

• The most common type of contrast given into a vein contains iodine. If a person with an iodine allergy is given this type of contrast, nausea or vomiting,sneezing, itching,or hives may occur.
• If you absolutely must be given such contrast, your doctor may give you antihistamines (such as Benadryl) or steroids before the test.
• The kidneys help remove iodine out of the body. Those with kidney disease or diabetes may need to receive extra fluids after the test to help flush the iodine out of the body.

Rarely, the dye may cause a life-threatening allergic response called anaphylaxis. If you have any trouble breathing during the test, you should notify the scanner operator immediately. Scanners come with an intercom and speakers, so the operator can hear you at all times.

Alternative Names

CAT scan; Computed axial tomography scan; Computed tomography scan

Chemo Therapy

Gemcitabine

Trade Name: Gemzar ^®

Drug Type:

Gemcitabine is an anti-cancer (“antineoplastic” or “cytotoxic”) chemotherapy drug.  Gemcitabine is classified as an antimetabolite.  (For more detail, see “How Gemcitabine Works” below).

What Gemcitabine Is Used For:

• Pancreas cancer
• Non-small cell lung cancer
• Bladder cancer
• Soft-tissue sarcoma
• Metastatic breast cancer

Note:  If a drug has been approved for one use, physicians sometimes elect to use this same drug for other problems if they believe it might be helpful.

How Gemcitabine Is Given:

• Gemcitabine is given by infusion through a vein (intravenously, by IV).
• There is no pill form of Gemcitabine.
• The amount of Gemcitabine you will receive depends on many factors, including your height and weight, your general health or other health problems, and the type of cancer you have.  Your doctor will determine your exact dosage and schedule.

Side Effects of Gemcitabine:

Important things to remember about the side effects of Gemcitabine:

• Most people do not experience all of the side effects listed.
• Side effects are often predictable in terms of their onset, duration and severity.
• Side effects are almost always reversible and will go away after treatment is complete.
• There are many options to help minimize or prevent side effects.
• There is no relationship between the presence or severity of side effects and the effectiveness of the medication.

The following side effects are common (occurring in more than 30%) for patients taking Gemcitabine:

• Flu-like symptoms(muscle pain, fever, headache, chills, fatigue)
• Fever  (within 6-12 hours of first dose)
• Fatigue
• Nausea (mild)
• Vomiting
• Poor appetite
• Skin rash
• Low blood counts.  Your white and red blood cells and platelets may temporarily decrease.  This can put you at increased risk for infection, anemia and/or bleeding.

Nadir: Meaning low point, nadir is the point in time between chemotherapy cycles in which you experience low blood counts.

Onset: none noted
Nadir: 10-14 days
Recovery: day 21

• Temporary increases in liver enzymes
• Blood or protein in the urine

These are less common side effects (occurring in 10-29%) for patients receiving Gemcitabine:

• Diarrhea
• Weakness
• Hair loss
• Mouth sores
• Difficulty sleeping
• Shortness of breath (see lung problems)

Not all side effects are listed above, some that are rare (occurring in less than 10% of patients) are not listed here.  However, you should always inform your health care provider if you experience any unusual symptoms.

When To Contact Your Doctor or Health Care Provider:

Contact your health care provider immediately, day or night, if you should experience any of the following symptoms:

• Fever of 100.5ºF (38ºC) or higher, chills (possible signs of infection)

The following symptoms require medical attention, but are not emergency situations.  Contact your health care provider within 24 hours of noticing any of the following:

• Nausea that interferes with eating and is not relieved by medications prescribed by your doctor.
• Vomiting (more than 4-5 episodes within a 24-hour period)
• Extreme fatigue (inability to perform self-care activities)
• Diarrhea (more than 4-6 episodes in a 24-hour period)
• Unusual bleeding or bruising
• Black or tarry stools, or blood in your stools or urine

Always inform your health care provider if you experience any unusual symptoms.

Gemcitabine Precautions:

• Before starting Gemcitabine treatment, make sure you tell your doctor about any other medications you are taking (including prescription, over-the-counter, vitamins, herbal remedies, etc.).  Do not take aspirin or products containing aspirin unless your doctor specifically permits this.
• Do not receive any kind of vaccination without your doctor’s approval while taking Gemcitabine.
• Inform your health care professional if you are pregnant or may be pregnant prior to starting this treatment. Pregnancy category D (Gemcitabine may be hazardous to the fetus.  Women who are pregnant or become pregnant must be advised of the potential hazard to the fetus).
• For both men and women: Do not conceive a child (get pregnant) while taking Gemcitabine. Barrier methods of contraception, such as condoms, are recommended. Discuss with your doctor when you may safely become pregnant or conceive a child after therapy.
• Do not breast feed while taking Gemcitabine.

Gemcitabine Self Care Tips:

• For flu-like symptoms, keep warm with blankets and drink plenty of liquids.
• Drink at least two to three quarts of fluid every 24 hours, unless you are instructed otherwise.
• You may be at risk of infection so try to avoid crowds or people with colds, and report fever or any other signs of infection immediately to your health care provider.
• Wash your hands often.
• To help treat/prevent mouth sores, use a soft toothbrush, and rinse three times a day with 1/2 to 1 teaspoon of baking soda and/or salt mixed with 8 ounces of water.
• Use an electric razor and a soft toothbrush to minimize bleeding.
• Avoid contact sports or activities that could cause injury.
• To reduce nausea, take anti-nausea medications as prescribed by your doctor, and eat small, frequent meals.
• Avoid sun exposure.  Wear SPF 15 (or higher) sunblock and protective clothing.
• In general, drinking alcoholic beverages should be kept to a minimum or avoided completely.  You should discuss this with your doctor.
• You may experience drowsiness or dizziness; avoid driving or engaging in tasks that require alertness until your response to Gemcitabine is known.
• Get plenty of rest.
• Maintain good nutrition.
• If you experience symptoms or side effects, be sure to discuss them with your health care team.  They can prescribe medications and/or offer other suggestions that are effective in managing such problems.

Monitoring and Testing While Taking Gemcitabine:

You will be checked regularly by your doctor while you are taking Gemcitabine, to monitor side effects and check your response to therapy.  Periodic blood work will be obtained to monitor your complete blood count (CBC) as well as the function of other organs (such as your kidneys and liver) will also be ordered by your doctor.

How Gemcitabine Works:

Cancerous tumors are characterized by cell division, which is no longer controlled as it is in normal tissue.   “Normal” cells stop dividing when they come into contact with like cells, a mechanism known as contact inhibition.  Cancerous cells lose this ability.  Cancer cells no longer have the normal checks and balances in place that control and limit cell division.  The process of cell division, whether normal or cancerous cells, is through the cell cycle.  The cell cycle goes from the resting phase, through active growing phases, and then to mitosis (division).

The ability of chemotherapy to kill cancer cells depends on its ability to halt cell division.  Usually, the drugs work by damaging the RNA or DNA that tells the cell how to copy itself in division.  If the cells are unable to divide, they die.  The faster the cells are dividing, the more likely it is that chemotherapy will kill the cells, causing the tumor to shrink.  They also induce cell suicide (self-death or apoptosis).

Chemotherapy drugs that affect cells only when they are dividing are called cell-cycle specific.  Chemotherapy drugs that affect cells when they are at rest are called cell-cycle non-specific.  The scheduling of chemotherapy is set based on the type of cells, rate at which they divide, and the time at which a given drug is likely to be effective.  This is why chemotherapy is typically given in cycles.

Unfortunately, chemotherapy does not know the difference between the cancerous cells and the normal cells.  Chemotherapy will kill all cells that are rapidly dividing.  The “normal” cells will grow back and be healthy but in the meantime, side effects occur.  The “normal” cells most commonly affected by chemotherapy are the blood cells, the cells in the mouth, stomach and bowel, and the hair follicles; resulting in low blood counts, mouth sores, nausea, diarrhea, and/or hair loss.  Different drugs may affect different parts of the body.

Gemcitabine belongs to the family of drugs called antimetabolites.  Antimetabolites are very similar to normal substances within the cell.  When the cells incorporate these substances into the cellular metabolism, they are unable to divide.  Antimetabolites are cell-cycle specific.  They attack cells at very specific phases in the cycle.  Antimetabolites are classified according to the substances with which they interfere:

• Folic acid antagonist:  Methotrexate
• Pyrimidine antagonist:  5-Fluorouracil, Foxuridine, Cytarabine, Capecitabine, and Gemcitabine
• Purine antagonist:  6-Mercaptopurine and 6-Thioguanine
• Adenosine deaminase inhibitor:  Cladribine, Fludarabine and Pentostatin

Cancer of the Bladder Diagnosis

Cancer of the Bladder Diagnosis is performed with a cystoscopy and bladder biopsy. Depending on the extent that bladder cancer grows into and along the bladder wall determines how involved your procedure will be. As explained on the previous page there is many diagnostic tests to evaluate bladder cancer. These tests help the urology surgeon determine what stage your cancer of the bladder is in. With the staging or bladder cancer analysis done the bladder surgery and treatment can be planned.

Cancer of the bladder diagnosis continues even as surgery is performed. The staging of the bladder cancer is evaluated with several elements. The first is how far the cancer has grown down into the bladder.
There are four layers that urologists deem distinct with each layer growing deeper into the bladder.

1. Cancer growing on the bladder lining and its connective layer underneath it.
2. Cancer that has grown down into the bladder muscle layers.
3. Cancer that has grown down into the fatty tissue.
4. Cancer that has gone through the bladder into other tissues and organs near the bladder.

The second element they evaluate is if the cancer has spread to the lymph nodes. The third element takes into consideration any organs that have acquired cancer that that are not in the area of the bladder. All of these facts are used to stage the bladder cancer.

Cancer of the bladder diagnosis sets the stage for the treatment. Treatments range from scrapping out shallow bladder tumors and applying some biological medication to the bladder while extensive and metastasized bladder cancer may include a cystectomy (bladder removal) with the removal of the prostate (radical prostatectomy)in men, and a hysterectomy in women.
When the bladder is removed then a new passage and reservoir needs to be created by the bladder cancer surgeon for the urine to pass and be stored.

Cancer of the bladder diagnosis that is determined from the battery of diagnostic test will be confirmed or reevaluated once surgery has begun. When the diagnosis of bladder metastasis has been determined then chemotherapy or radiation treatments may be included.