Diagnosing cancers is all too often a challenge. In a recent
article in the Wall Street Journal, an Oncologist bemoans the fact that
medicine has made little progress in this effort and worse the means and
methods of treating the more advanced forms is still archaic and brutal[1].
The author specifically argues[2]:
What we need now is a paradigm shift. Today, the newest
methods generating the most research and expense tend to be focused on treating
the worst cases—chasing after the last cancer cells in end-stage patients whose
prognoses are the worst. We need instead to commit to anticipating, finding and
destroying the first cancer cells. We must reliably detect the faint footprints
of cancer at the beginning and stop it in its tracks.
Such prevention represents the cheapest, fastest and
safest alternative to the terrible, longstanding treatment trio of slash,
poison and burn. It’s the most universally applicable way to save lives, and
the estimated cost-savings from early diagnosis add up to over $26 billion a
year, more than any other new approach can promise. Earlier detection is also
the most humane way to improve cancer outcomes. Status quo treatments—the
combination of surgery, chemotherapy and radiation for solid tumors, or chemo
and bone marrow transplants for liquid ones—can be brutal and indiscriminate
killers. Treatments often leave patients in agony, while providing mere months
of added survival. The new immunotherapies can be even more.
The author's construct of the faint footprints is compelling
but alas a distant goal. We simply cannot test everyone for everything. Various
Government bodies bemoan using the PSA test for prostate cancer while allowing
massive usage of mamographies and identifying numerous DCIS yet denying PSA
testing. Many Internists may miss the most obvious of melanomas while
identifying various cardiac arrythmias.
We have previously discussed the issue of just what is a
cancer. We used PCa and thyroid cancers as examples. Thyroid cancers,
especially microcarcinomas are small collections of ill formed cells showing
certain aberrant nuclear formations. Yet there is no evidence that they would
ever metastasize. HGPIN in the prostate has the ability to just disappear
rather than progress. Bladder tumors are often CIS, and may be evident due to
small hematuria.
These may all lead to highly invasive tests and even more
invasive and putatively morbid surgeries. Thus, despite the authors plea, many
of these putative cancers are all too often remedied by the patient's own
immune system. On the other hand, the same immune system may be used against
the patient to protect and nourish the ever-growing lesion. Perhaps there is no
simple answer. Indeed, in cancers there are too often no simple answers.
We examine herein some of these issued as focused on bladder
cancer, BCa, a malignancy which is on the on hand complex, and on the other all
too often a chronic disease.
Bladder cancer is a malignancy of parts of the bladder. It
is not as common as prostate yet can be costly to treat because of ongoing
recurrence. As NCBI notes[3]:
Bladder cancer is a disease in which certain cells in the
bladder become abnormal and multiply without control or order. The bladder is a
hollow, muscular organ in the lower abdomen that stores urine until it is ready
to be excreted from the body. The most common type of bladder cancer begins in
cells lining the inside of the bladder and is called transitional cell
carcinoma (TCC). Bladder cancer may cause blood in the urine, pain during
urination, frequent urination, or the feeling that one needs to urinate without
results. These signs and symptoms are not specific to bladder cancer, however.
They also can be caused by noncancerous conditions such as infections.
Currently the diagnosis of bladder cancer is performed by a
cystoscopic exam, excision of tissue, and histo-pathological examination. There
is now a proliferation of extensive imaging technologies which arguably provide
alternatives to such a process. We examine some of these modalities herein and
look at them in the context specifically of bladder cancer. In a recent paaper we pose a prime question examined herein is:
Can imaging
modalities, especially mpMRI, be used as an adjunct in staging bladder cancer?
Furthermore, can mpMRI be used in place of invasive pathological studies in
diagnosing, staging and prognostic evaluation of bladder cancer?
We use existing literature to consider this issue.
Specifically, we examine:
1. The current understanding of bladder cancer, BCa, and how
it is diagnosed, staged and treated. These are generally histo-pathologic
measures of cell structure, morphology, and aggregates of cells as well as some
immunohistological measures.
2. The underlying measures which can be obtained
non-invasively that reflect the existence of BCa with such samples as miRNA,
proteins, DNA, and other exomic measures.
3. The target genetic changes which relate to the initiation
and progression of BCa.
4. The use of a multiplicity of imaging modalities which
assist in diagnosis
5. The specific use of mpMRI, using multiple MRI modalities,
to assess their ability to non-invasively diagnose, stage, and give prognostic
data.
6. A discussion of a multiplicity of related issues
including the putative application of AI.
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