Edible pot vs. smoked pot; mental health services for youth; bladder cancer and treatment: Upstate Medical University's HealthLink on Air for Sunday, Feb. 13, 2022
Toxicologist Willie Eggleston, PharmD, discusses the effects and dangers of marijuana edibles compared to marijuana that is smoked. Child psychologist Ron Saletsky, PhD, goes over child and adolescent mental health services. Urologic oncologist Joseph Jacob, MD, explains bladder reconstruction and removal for treatment of advanced bladder cancer.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a toxicologist discusses the effects and dangers of marijuana edibles compared to marijuana cigarettes.
Willie Eggleston, PharmD: ... When you think about smoking versus edibles, smoking works fast, lasts for a short amount of time. Edibles take a long time to start, and once they start, they last for a very long time ...
Host Amber Smith: A child psychologist goes over the mental health services available to children and adolescents in Central New York.
Ron Saletsky, PhD: ... That could include individual therapy, family therapy, parent-child relational therapy, group therapy ...
Host Amber Smith: And a urologic oncologist explains bladder reconstruction and removal for treatment of advanced bladder cancer.
Joseph Jacob, MD: ... There are other options as well, but the most definitive treatment for patients would be the removal of the bladder ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we talk with a child psychologist about the mental health crisis affecting children and adolescents. Then, a urologic oncologist discusses advanced bladder cancer and the three surgeries he offers for bladder reconstruction. But first, a toxicologist compares the dangers and effects of marijuana edibles and marijuana cigarettes.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Marijuana edibles are legal in New York state for adults 21 and older, but that doesn't mean they're safe to use. For help understanding what to watch out for, I'm speaking with Dr. Willie Eggleston. He's a clinical assistant professor of emergency medicine specializing in toxicology, and he's part of the Upstate New York Poison Center.
Welcome back to "HealthLink on Air," Dr. Eggleston.
Willie Eggleston, PharmD: Thanks, Amber. I'm happy to be here.
Host Amber Smith: To begin, I'd like to ask you to explain what cannabis does to the body. How does it work?
Willie Eggleston, PharmD: Well, that's a big question. In general, when we think about cannabis or marijuana, it's important to remember we're talking about the plant or things derived from the plant. And so there's a lot of different chemicals and compounds in there that can have a lot of different effects on the body. In general, marijuana can cause some sleepiness, some sense of euphoria, and generally that's the reason that people are seeking out its use.
Host Amber Smith: So the big ones that we hear about, the big initials we hear about are CBD and THC. Are both of these things in marijuana?
Willie Eggleston, PharmD: They are. And depending on how you grow the plant, they can be there in different concentrations, and they have very different effects on the body. So THC is the one that people are typically experiencing the sensations that they're familiar with when they use marijuana. It's the psychoactive component of marijuana. It's the part that causes the euphoria. It's the part that causes the high that people are seeking out when they're using marijuana. CBD is a little bit different. It actually blocks the effects of THC at the main receptor, and it can cause a whole host of different effects that are still being researched for medicinal reasons today in the United States.
Host Amber Smith: So it is my understanding, you can find products that have both CBD and THC, and you can find products that are CBD only. Can you also find products that are THC only?
Willie Eggleston, PharmD: So, any product that you're using that is marijuana or derived from marijuana is going to have both in there. Now, people can manipulate the plant in ways that increase one or decrease the other. And so it's important to look at the dosing on the product you're using, if it's available. You can find CBD-only products currently available in New York and across the United States. These are derived from hemp. Hemp is a special strain of marijuana that contains no THC, and so you're able to get CBD from that plant. It's harder to get products that are just THC with no CBD, but certainly there are recreational products available that have very, very high concentrations of THC and very, very low concentrations of CBD. So you can find things all across the spectrum.
Host Amber Smith: So it sounds like the products are going to differ quite a bit. What symptoms may indicate that someone is having a bad reaction to the product they've used?
Willie Eggleston, PharmD: So some of the more common adverse effects that are reported to us include things like what's called a dysphoric reaction. You might think of that as like a "bad trip." So that can depend on that individual, that individual's experience with marijuana, the setting that they're using the product in. But in general, what that can mean is a fast heart rate, anxiety, being worried about everything going on around you, heightened awareness. And so certainly that can lead to someone having a, what we would consider a bad reaction to the product. Outside of that, certainly because it does cause the individual to become more sleepy, and it delays their reaction time, there can be difficulty with completing tasks that are normally easy to do. So we encourage people not to use this if they're going to have to do any tasks that involve a thought process or quick reaction time. It's just not a good combination.
And then lastly, there's some ongoing research to suss out how risky is this for individuals with other chronic diseases, for example, psychiatric diagnoses or heart conditions that may lead it to be more dangerous with longer-term use.
Host Amber Smith: I wonder, is there a difference in the way it's ingested -- smoking or vaping versus if you swallow it in an edible. Are the effects going to be different?
Willie Eggleston, PharmD: They are very, very different. And that's one of the important messages we want people to be aware of as recreational products become available in New York. We know that adult use of marijuana is coming. We know that dispensaries will be open soon. And so it's important for folks to understand if you've smoked a product in the past, and now you're using an edible, although the chemicals in there are the same, the way that they take root in your body is very, very different. When you smoke generally, you know the effects from that dose within three to five minutes. It's very, very rapid acting. And it goes away fairly quickly too. The effects are gone within a couple of hours. Whereas edibles, it takes about two to three hours to even start to feel the effects, and up to six hours to know how strong those effects are going to be. And once they start, they last for many, many hours. So in general, when you think about smoking versus edibles, smoking works fast, lasts for a short amount of time. Edibles take a long time to start, and once they start, they last for a very long time. So if it's your first time using an edible product, you want to start with a very low dose. You want to take that dose, and you don't want to take any more. Even if it's been an hour and nothing's happening, it doesn't mean nothing's going to happen two hours from now. So you really want to start low, see how that affects you, and then gradually you can increase with subsequent uses.
Host Amber Smith: You mentioned that research is ongoing into chronic conditions that people may have and how that may or may not be influenced. Is there any way a person can, sort of, predict what their reaction is likely to be?
Willie Eggleston, PharmD: There's really not. You know, we certainly know in individuals who use marijuana more frequently, they kinda know how their body reacts to the product. But in someone who just uses occasionally, we really don't have any good information to figure out who's going to have a bad reaction. In general, how much does it take, or how frequently does someone need to use it to develop something like a use disorder? Those are things that we're still trying to answer.
What we do know is that chronic use or regular use of marijuana can lead to something called cannabinoid hyperemesis syndrome. And that's a fancy medical way of saying the patient starts to vomit and they vomit a lot. They feel nauseous, they feel cruddy. And the typical medicines that we use to treat the nausea and vomiting don't work very well for cannabinoid hyperemesis syndrome. So it's certainly a problem, and it's one that public health officials and medical folks are trying to get a better response to, get a better handle on. But it's still an emerging issue that we're learning about.
Host Amber Smith: Why do people report getting the munchies when they, at least when they smoke marijuana? And I wonder, does that happen with edibles as well?
Willie Eggleston, PharmD: That's a great question. Yeah. Marijuana in the body is really a very fascinating thing, and it's something we don't know a whole lot about still, despite it being around for thousands and thousands of years. The receptors that marijuana binds to in the brain, we have more of those receptors than any other receptor in the brain. And they affect so many different organ systems, including our hunger. A couple of different changes happened when marijuana enters the body, one of which is it upregulates a hormone that tells us, "Hey, it's time to eat. I'm hungry." It's one of the reasons we can use a marijuanalike product to treat diseases in which patients have very low weights, and we need to increase their appetite. So it does do that. It does a whole host of other things. And it does that if you smoke it, if you vape it or if you ingest it.
Host Amber Smith: You're listening to Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with Dr. Willie Eggleston from the Upstate New York Poison Center. Dr. Eggleston is a clinical assistant professor of emergency medicine, and he specializes in toxicology.
Is marijuana addictive?
Willie Eggleston, PharmD: That's a little bit of a loaded question, but the short answer is yes. We have a spectrum of how addictive something can be. And we have things like opioids that we think of as a classic example of things that can cause a substance use disorder. And marijuana is on that spectrum. We just don't know where it is on that spectrum. It seems to be at the lower risk end, but in individuals who do use the product regularly, frequently, we know it can interfere with their job, with their life, with their family and relationships, with legal problems. And it does have a withdrawal when you take the drug away. And so it does cause a use disorder. We just don't know how frequently and how severe that use disorder is. And we're still learning about how to best treat that.
Host Amber Smith: You mentioned how it stays in the body longer if you consume it as an edible and that it could stay with you and feeling the effects of it for hours. So if someone's a recreational user on the weekend, how can they be sure that they'll be fresh to go to work Monday morning or school Monday morning?
Willie Eggleston, PharmD: It does stay for hours, but generally, the next day, it's out of your system from the psychoactive component. What I mean by that is that the compound that's in marijuana that causes the altered mental status, the delayed reaction time, the euphoria, that, even with edibles, that is generally at a low enough concentration the next day that it's not going to have any impact on you. When I talk about duration, meaning like instead of two or three hours with smoking, we're talking more like eight to 12 hours of duration with edibles.
Host Amber Smith: Are there any medications or supplements that are dangerous to use while using marijuana?
Willie Eggleston, PharmD: Sure. In general, we recommend not mixing marijuana with anything if possible. The effects of marijuana can be changed dramatically if they're taken with, particularly products that are sedating, so alcohol, benzodiazepines, medications used for sleep. They can really increase the effects of it on your reaction time and your sleepiness. And then when taken with stimulants, it can really increase potentially that risk for reactions that are not pleasant, dysphoric reactions. And so in general, mixing marijuana with other products is not a great idea. And as I said earlier, one of the populations where we're still learning about a risk of combining marijuana with other disease states: certainly older adults with cardiac conditions. We know that to be a potential risk for bad outcomes when mixed with marijuana.
Host Amber Smith: I'm assuming it's unsafe to drive under the influence of marijuana because you have slowed reaction and impaired judgment.
Willie Eggleston, PharmD: You are assuming correctly. Yes, it is absolutely dangerous to drive under the influence of marijuana. And we certainly recommend strongly against it.
Host Amber Smith: What about CBD-only products?
Willie Eggleston, PharmD: That's a tough question to answer. CBD-only products can cause you to be a little sleepy or drowsy when you use them. And so we do encourage the first time that someone's using a CBD product, they want to avoid things like driving or other activities that require coordination. But once someone is using a product and they know how they react to it, from there, they can kind of make decisions as to what's safe for them to do. In general, there's not a whole lot of research on CBD and its effects on driving or other activities that require reaction time. But marijuana, for sure, we have substantial research to demonstrate that it significantly delays reaction time, and it's not a good combination with someone driving a car.
Host Amber Smith: What about marijuana use during pregnancy or during breastfeeding?
Willie Eggleston, PharmD: So marijuana use during pregnancy has been fairly extensively researched. It's not like alcohol or other substances that impair the development of the unborn child. But the child, when they are born, sometimes they have a lower birth weight, so their weight is lower than that of a typical baby born to a mother not smoking marijuana. And sometimes that can lead to admissions to a neonatal intensive care unit, an ICU for babies. And we know that the incidence of babies going to the ICU is higher in mothers who smoke marijuana than those who don't. Aside from that, there's not a whole lot of other data to show that it's risky, versus not risky. There's no real compelling evidence to show that it has long-term effects on development once the baby's born. And as far as babies who are breastfed by mothers who smoke marijuana versus mothers who do not, again, we know that marijuana gets into the breast milk. We know that it gets into the baby's bloodstream, to some degree. But we really don't have any evidence to show that that has a detrimental effect on the baby.
Host Amber Smith: Interesting. Well, I'd like to ask you about storage of edibles. Do marijuana products have a shelf life, or does their potency fade over time?
Willie Eggleston, PharmD: In general, most edibles will have a similar shelf life to the product that they are made in as long as they're prepared correctly. So for example, an edible gummy will have a shelf life that is much longer than an edible cookie or an edible drink or an edible condiment. But when thinking about these products, as far as how to store them, I encourage people that even though a lot of the edibles are in food products, not to think about these as food products, to think about these as medications. When we worry about risk and exposure, the concerns that we have are magnified tenfold, a hundredfold when you think about kids getting into these products. An adult getting a little bit sleepy, no big deal. A kid getting the same dose of marijuana gets far more sleepy, can have difficulty with their breathing, may require admission to an intensive care unit. And so we encourage folks who have these in their home to store them up away out of sight, ideally in a locked container, to avoid those unintentional exposures in little kids.
Host Amber Smith: I wanted to ask you, if a child or even a pet at home ingests an edible, you know, accidentally, and someone calls the poison center for help, what are you likely to ask the person? What are you looking for?
Willie Eggleston, PharmD: So we'd be looking for signs and symptoms of the ingestion, which initially would include things like sleepiness. And most of the time, kids who get into these products, because they are so unpredictable, because they're not designed to be used in two- and three- and four-year-olds, they generally will require observation in an emergency department for their symptoms because they can get severe.
Host Amber Smith: What is the treatment for an overdose? A person could take way too much, eating too many edibles. I can see where that would happen. If the effects don't happen, and they think, "Oh, I need more," someone could really ingest quite a bit of this before they get into trouble. What is a treatment for an overdose?
Willie Eggleston, PharmD: We don't have an antidote. There's not something we can give someone to reverse the effects of marijuana in the body. It's mostly just using the medications we have to treat the symptoms that are present until the marijuana has left the body. So for example, if someone is very anxious and nervous and they're having a bad trip, we can give them medications to calm and relax them. But it's mostly just supporting the patient until the marijuana is out of their system, they're back to their normal baseline, and they can safely go home.
Host Amber Smith: Well, this has been very informative. I really appreciate you taking time to explain this to us.
Willie Eggleston, PharmD: Oh, sure. Absolutely.
Host Amber Smith: My guest has been Dr. Willie Eggleston from the Upstate New York Poison Center. He's a clinical assistant professor of emergency medicine, specialized in toxicology at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
What mental health services are available for children and adolescents -- next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children's Hospital Association jointly declared a national state of emergency in children's mental health. There were challenges before the pandemic, which has only made things even more challenging. So today I'm talking about this with Dr. Ron Saletsky. He's a child psychologist at Upstate, where he's a professor of psychiatry and behavioral sciences, and a professor of pediatrics. Welcome to "HealthLink on Air," Dr. Saletsky.
Ron Saletsky, PhD: Thank you so much, Amber. I appreciate the opportunity to talk about mental health services for children and families at Upstate.
Host Amber Smith: This is such a serious topic, and it's a very real crisis for so many families, so I wanted you to tell us about the types of mental health services that are available at Upstate for children and adolescents.
Ron Saletsky, PhD: Absolutely. I just, as I began, I just want to reiterate what you said, that the mental health challenges for kids and families are greater than ever these days. Rates of depression and anxiety in children and youth that had already been steadily increasing over the last decade have been exacerbated by the pandemic, and, as such, the stress level for families as a whole has also risen. So this is, for lack of a better word, a bit of a crisis time for kids and families. There are absolutely outpatient services available, for emotional and behavioral problems in children here at Upstate. We typically work with kids at about pre-K age, so 3 and 4 years old, up through 18, and their families. All of the services are available at the department of psychiatry. Certainly there are mental health providers all over Upstate, and I can talk about that in a minute, but the largest group of providers is clearly at the department of psychiatry. Within the department, we offer a couple of groups of providers. One are our staff at University Hospital child and adolescent psychiatry clinic. And the other is the faculty practice group. Both offer highly skilled clinicians of multiple disciplines, and certainly virtual appointments are available.
Host Amber Smith: I wondered about that because during the pandemic, I know a lot of doctors have been offering that. Does that work for psychiatric issues?
Ron Saletsky, PhD: Well, it's a challenge. It's a barrier between, you know, it's a relational business that we're in as mental health providers. And whenever you put something in between, it can be a barrier. However, we've had a lot of experience with it over the last year, just because of the pandemic. And it is possible to offer and receive high-quality services. It is more difficult with the youngest kids because keeping them on-screen, I mean, they're having the same difficulties at school as well when school goes remote. So keeping kids on-screen and focused can be a challenge, but that also provides an opportunity to work more closely with the parents. And it is in our view, the parent is the primary healing agent in the child's life. So it does give the opportunity to do that.
Host Amber Smith: So with the mental health services, is it family therapy? Is it group therapy? Is it one-on-one? What is it?
Ron Saletsky, PhD: We offer a whole range of services, and we choose the therapy based on a really thorough assessment of what's going on, an assessment of the problem. And then we choose from a number of possible interventions that could include individual therapy, family therapy, parent-child relational therapy, group therapy. We offer the whole range, and also parent guidance, as well. And again, the type of therapy that's chosen is based on a really thorough assessment that's done in the beginning.
Host Amber Smith: How would you advise people to access the child and adolescent mental health services at Upstate?
Ron Saletsky, PhD: So, as I said earlier, we have two entry points. One is through the University Hospital child and adolescent outpatient clinic. And that phone number is 315-464-3165, and the parent would ask for intake and then describe what's going on. The other entry point is the faculty practice group, and that number is 315-464-3265. And again, the same questions would be asked in terms of, why are you calling, and you would ask for intake and then describe what was going on and see what practitioners might be available.
Host Amber Smith: Do people need to have a referral from a pediatrician?
Ron Saletsky, PhD: No, not necessarily.
Host Amber Smith: OK. If someone needs inpatient care, that's available, right?
Ron Saletsky, PhD: Inpatient care is available, yes. There are, as you alluded to, there's a shortage of inpatient beds both locally, regionally and nationally, but we do have inpatient care in Syracuse. We have an adolescent unit, a newly developed unit over the last two years, called 7-West that's in University Hospital. It's a short-term unit. Stabilization and discharge. Basically length of stays between one to two weeks, and then, kids get discharged to appropriate level of services post-hospitalization. We also have Hutchings Psychiatric Center here in Syracuse, which has a small amounts of beds at this point. They've decreased their census and the number of beds, and they can also be an option for children locally. So between the Upstate unit and Hutchings, those are our local beds.
Host Amber Smith: How long is the typical stay for children and adolescents?
Ron Saletsky, PhD: These are short-term units, especially the one at Upstate is a short-term unit. We're talking about one to two weeks, at the most, for stabilization. Every so often there's a child that may have to stay longer because of the intensity of their symptoms. But usually they limit it to one to two weeks so that there is significant turnover, so more kids can be served.
We do have an intensive adolescent program, which is really a step down from the hospital, which, sometimes when you go from the hospital, which is really intensive, you need a middle-ground program to continue to help you consolidate the skills that the kids are learning to not engage in such risky behavior and to develop more adaptive skills. We have these kind of special programs -- one is through the faculty practice, and one is through the clinic -- that really work with high-risk youth.
Host Amber Smith: Well, I know that it's difficult to find mental health care services across the nation right now, because everyone is in this crisis. Do you have any advice for what families can do in the meantime?
Ron Saletsky, PhD: It's really tough. I think if parents can commiserate with other parents, that can often help diffuse some of the responsibility and maybe, allow parents to get some tips in terms of working with their children. Also primary care physicians, either family docs or pediatricians, can also be a source of support. Here at Upstate, we have, if a family is, their child is, a patient at one of our Upstate pediatric outpatient clinics, we do have some mental health services that are embedded into those clinics called integrated care. And there are some possibilities there, as well, where kids can be seen in short-term work, but again, as I said before, the main source of outpatient services is at the department of psychiatry.
Host Amber Smith: That's good to know. Now, take an emergency situation where a parent feels like they're out of options. Are they advised to come to the pediatric emergency department at Upstate? And if so, can you walk us through what would happen?
Ron Saletsky, PhD: Let me just start by saying emergency situations are incredibly scary, not only for the child, but for the parent as well. No parent wants to see their child potentially harm themselves, harm other people. So if the child or adolescent is struggling with high-risk behaviors, and those include suicidal thoughts, self-harm, harming others or losing touch with reality. And what I mean by that is hearing voices or seeing things that others don't see or hear. Then the safety of hospitalization may be what is needed. The inroad to hospitalization, as you said, is the emergency room. We do have two places where kids who are in psychiatric emergency would go in this community. One is CPEP, the Community Psychiatric Emergency Program at St. Joseph's Hospital. And the other is Upstate's pediatric emergency room. I can speak about Upstate. I don't work at St Joe's, but at Upstate, as I said before, if needed, we offer an eight-bed, short-term psychiatric unit for adolescents. OK? When there is a crisis and in an emergency, the parent would bring their child or get their child to the Upstate emergency room. At that point, the child and family would be interviewed by the consultation team or the emergency room team in order to determine current level of risk to the child's safety. That is the determining point. If the child is engaging in risky behavior and the risk is deemed high enough, then they may need the higher level of care that the hospital can provide. So if the risk is sufficiently high, inpatient hospitalization will be recommended. If there are no beds available on the local unit on 7-West or at Hutchings, or even in the regional units, the child, because of safety issues, will be admitted to Golisano Children's Hospital until a psychiatric bed opens up or until the level of risk decreases sufficiently for discharge to appropriate outpatient services. So if a child is at risk, nobody's going to just let them go back to the community. OK? There's too much risk there. There's too much on the line. A child will be admitted. It may not be to a psychiatric unit right away because there may not be openings, but they will get good care at Golisano, and maybe by the time a bed opens up the child's needs may have sufficiently decreased so that inpatient hospitalization might not be needed.
Host Amber Smith: You're listening to Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with Dr. Ron Saletsky, a child psychologist at Upstate. We're talking about the pediatric mental health crisis and the services available for children and adolescents in Central New York.
The nation, and not just Central New York, is facing a shortage of mental health care providers in general. And more severely, those who specialize in pediatrics. So let me ask you, what are the reasons for this shortage, and what do you think needs to be done to improve the situation long term?
Ron Saletsky, PhD: You know, I think the reasons are around supply and demand. Most child training for mental health clinicians, either in psychiatry, psychology, social work, nurse practitioner programs, they admit very few trainees. They are small programs to provide very, very in-depth training. Uh, we need more. We need more training programs. We need more people staying in Syracuse. We run several training programs here postgraduate. We have a psychology internship in child. We have a child psychiatry fellowship. We have a nurse practitioner fellowship. We have a social work internship. They go through these programs here at the Upstate department of psychiatry, and the hope is that we can keep them around so that we can grow the workforce that's needed to expand the programs that we offer.
Host Amber Smith: What do you yourself enjoy about being a child psychologist?
Ron Saletsky, PhD: Oh, wow. I can't think of anything else I could do or I'd rather do. I've been practicing as a psychologist for over 30 years. For me, I get the privilege of working with and helping people in need. Human beings are fascinating to me, as fascinating now as they were when I was in graduate school. Being able to have the honor of working with people when they are vulnerable, being allowed in to their lives, getting to know them, using whatever skills I have to help them gain more control over their lives. To me, there's nothing more gratifying. In addition, because I'm a psychologist here at Upstate, I work with professionals from other disciplines, and we found that certainly providing multidisciplinary care is the best care possible. Also in my position at Upstate, I got to teach and supervise future child mental health practitioners to hopefully add to the skilled workforce. And that's a wonderful experience, and it keeps me really sharp. The field that I'm in is one that you can continue to grow until you're done. And that's really exciting to me. And I can't think of anything else I'd rather do.
Host Amber Smith: As you're working with the incoming students, what traits do you see in a person that you can say, "Well, that person's going to make a really good child psychologist"? I'm trying to understand what kind of person could get into this career and do well in it.
Ron Saletsky, PhD: There are, I think, lots of variables that go into it, but I think people are , born with certain skills, be they artistic, be they scientific, be they people skills, being able to understand and be in tune with people's emotions and thinking and interactions. I think there's a certain level of that, that you need to be really good at what I do, what we do as child mental health practitioners. A love of children, a curiosity, a motivation. I think curiosity is really, really important because it keeps you fresh. You don't see everybody as the same. You view people individually when you have unique curiosity. Those kinds of traits, I think are really, really important. You can learn the therapeutic technique. That's what graduate school is about. That's what internship is about, but you're really coming into it with a certain skill set and, for lack of a better way of saying it, a certain instrument that you have, that's attuned to people and with continued experience and supervision, you get to hone that instrument. And, yeah, it's a complicated set of skill set, but I think part of it, you come into the world with.
Host Amber Smith: Well, thank you so much for making time for this interview.
Ron Saletsky, PhD: Of course. My pleasure.
Host Amber Smith: My guest has been child psychologist Dr. Ron Saletsky, a professor of psychiatry and behavioral sciences, and a professor of pediatrics at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air": options for bladder reconstruction.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Treatment for some advanced bladder cancers may include surgical removal of the bladder. Today I'm talking with urologist Dr. Joe Jacob about options. We'll cover bladder replacement, urinary reservoirs, and possible ways of preserving the bladder. Dr. Jacob is director of the bladder cancer program at Upstate. I thank you for making time for this talk, Dr. Jacob.
Joseph Jacob, MD: Thank you so much for having me.
Host Amber Smith: Now, I want to be clear that most people with bladder cancer can be treated without facing the removal of their bladder. Is that right?
Joseph Jacob, MD: That's correct. So 70% of the time -- which is something that we're happy about -- this'll be a superficial or a non-muscle-invasive bladder cancer. So 70% of the time we can manage patient's bladders with scraping, endoscopic procedures, which are camera procedures where we look in and we can do some work through camera. And a lot of times we'll do bladder treatments. We call them intravesical treatments. So these are treatments that we give patients into their bladder, through a catheter.
Host Amber Smith: So there's 30% that may face an issue with the bladder possibly needing to be removed, is that right?
Joseph Jacob, MD: That's correct.
Host Amber Smith: What are the reasons for that? Why would a bladder need to be removed?
Joseph Jacob, MD: When the bladder cancer invades into the muscle, it has a very high chance of spreading outside the bladder. And at that point it can become very dangerous for the patient. So when you have muscle-invasive bladder cancer -- so, very important -- there's a big distinction between non-muscle-invasive bladder cancer and muscle-invasive bladder cancer. So when patients have muscle-invasive bladder cancer, if you don't do something aggressive, such as remove the bladder, most of the time, this will spread. Almost hundred percent of the time this will spread into the bloodstream and the lymph nodes. And then at that point, there's no cure for the patient.
Host Amber Smith: This muscle-invasive bladder cancer, does it affect men and women equally?
Joseph Jacob, MD: No -- sorry, guys; again, this is more common in men. But it does happen in women. And one of the important things to understand with women is, a lot of times, women present at later stages because they just are thinking that it's a UTI (urinary tract infection), or their bladder symptoms are just part of, quote unquote, being a woman. And unfortunately they're diagnosed later than men are.
Host Amber Smith: So symptoms of a urinary tract infection ... do those sometime get mistaken as bladder cancer and vice versa?
Joseph Jacob, MD: Yes. Yes, exactly. And so the most common way we pick up bladder cancers is when people have blood in their urine. And so you can imagine, a woman sees blood in her urine and says, "Oh, it must just be a UTI." Or even, someone that they see, some kind of provider that they see, say, "Hey, take some antibiotics. You know, the most common thing would be UTI." And, possibly, bladder cancer could be missed.
Host Amber Smith: So let's go over, what are the symptoms that are most alarming? You mentioned blood in the urine. Is that the main symptom that you shouldn't ignore?
Joseph Jacob, MD: That's the main reason why people present to a urologist, and that would be the most common way that we pick up bladder cancers. The other way would be people that come in with symptoms, whether it be pain or discomfort, and we would sometimes look in with a camera. So the way to diagnose this would be someone comes in with blood in the urine. And then we would obtain a CT scan and do what's called cystoscopy, which is taking a camera and looking inside the bladder.
Host Amber Smith: So let me ask you, the cystoscopy, is that how you find out whether it's muscle invasive or not?
Joseph Jacob, MD: It is. Cystoscopy means just looking in, and then we would do biopsies with the guidance of the camera. And based on the biopsy, we send everything to the pathologist, and so the pathologic report would tell us, is this in the muscle or not in the muscle?
Host Amber Smith: You're listening to Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with Dr. Joe Jacob. He's a urologist and director of the bladder cancer program at Upstate.
So let me ask you about the options, the typical options, for someone who has muscle-invasive bladder cancer. And if you've got to talk to them about removing the bladder, what sorts of options might a person have?
Joseph Jacob, MD: The most standard-of-care treatment is removal of the bladder, which we call a cystectomy. There are other options as well, but the most definitive treatment for patients would be the removal of the bladder. So what happens is for a man, the bladder is removed. The prostate's also removed. Lymph nodes are also removed. So once you remove the bladder, obviously you've got to figure out: Where does the urine go? So the kidney filters the blood and creates urine. And these kidney tubes called ureters that take urine down toward the bladder. So once you remove the bladder, you're going to figure out, what do you do with the urine?
And so there's three different options that patients have after removal of the bladder. The most common option would be what's called a urinary conduit, or a urostomy. And that's sort of similar to what it sounds, you know, conduit or a pipe. It's a small piece of small bowel, of ileum, that we turn into a pipe where it just sends urine from the kidneys right out to the skin. And then this gets collected with a stoma bag or stoma appliance. So this bag fills up with urine. When the bag fills up, you unscrew the valve and you dump the urine in the toilet, and then you go on with your day. The reason why this is the most common approach is, it's the most straightforward, it's the easiest one to sort of take care of. But it may not be the most appealing to patients from like a quality of life standpoint or an appearance or aesthetic standpoint.
Host Amber Smith: So what are the alternatives to a urinary conduit?
Joseph Jacob, MD: So one other option is called a neobladder, or a bladder replacement. And you would take more small bowel, or ileum, so just a little bit more than you would for a conduit. And I tell patients we do some origami work, but basically you're folding this bladder into a sphere. And then you connect that bladder back to the urethra, and the patient would learn how to urinate like they're used to urinating. So a guy would urinate from their penis, and a woman would urinate from the urethra or vagina.
Host Amber Smith: Interesting. Now what you've described, taking the patient's small bowel and reformatting it in some way, those sound like very extensive surgeries.
Joseph Jacob, MD: They are. This is one of the bigger surgeries that patients can receive. And you sort of want to optimize patients before, just because it's such a big surgery. I mean, they stay in the hospital for at least three days. It takes about a month or two, really, to recover from these surgeries. So you want to do the surgery, obviously, with someone you trust, but also in a center of excellence where they're used to doing a lot of these surgeries. A lot of times little issues here and there come up or, you just need someone that has experience or a facility that has experience dealing with these, we call them little bumps in the road or little setbacks that can happen after such big surgery, just to get you through the first couple months.
Host Amber Smith: Does every patient who says, "Well, I'd like the neobladder option," are they all candidates for that? Or are there specific things that you look for to determine whether it's going to be a success for that particular person?
Joseph Jacob, MD: That's a great question. Really it's a patient decision. There's a couple of rare things that would disqualify someone from having a neobladder. So if there's a lot of cancer near the urethra, and we have to remove the urethra, then obviously you can't really connect the neobladder if there's no, if there's no urethra. So that would be one rare thing. And then one thing that could also happen that's rare is sometimes the blood supply to the bowel is so tight that it doesn't reach down to the pelvis, down to where you need to get it to. But most of the time, if the patient wants to have that kind of surgery, then we can get it done for them.
Host Amber Smith: Once the person recovers from a surgery like this, how long is this bladder going to function? Is it meant to last the rest of their lifetime?
Joseph Jacob, MD: It is. So as long as you take care of it, and we help patients do that. That's another thing. You can do the surgery but you also need someone that's experienced, in a facility that's experienced, that has resources to help you manage the bladder, to help, to teach you how to take care of it and to follow you and to make sure that you're surveyed properly, so that we can ensure that this is going to last the rest of your life.
Now, the other option is called an Indiana pouch, or a continent urinary reservoir. And that's similar to the neobladder except you take the right colon, and you use part of the ileocecal valve. So a lot of complicated words, but basically you're taking part of the colon, and there's a natural valve where the small bowel enters the colon so that stool doesn't go backwards into the small bowel. We use that natural valve, and so we form a pouch out of the colon, and then we use a catheterizable channel with that valve so that when patients want to empty this, they catheterize this channel, we call it. And that's the way you empty it. And so the nice thing about that is you're not using a stoma. We call it a continent diversion, so there's not always urine pouring out that has to be collected into a bag. The way you drain this is you catheterize this via small opening in the side of your abdomen, a small opening in the skin.
Host Amber Smith: It sounds like there would be a lot of education that would come with how to live with these bladder alternatives afterwards.
Joseph Jacob, MD: Definitely. You need someone that understands all the nuances and all the different things that can come up, all the little setbacks that can come up and be able to deal with them. But in general, if the patient wants that kind of procedure and is willing to work at it and learn, we can get them there and make it work for them. Everyone has different priorities in their life, and so for example, younger men, a lot of times they don't want to deal with a stoma, and they want to be able to feel like they're peeing sort of normally. So neobladder would be common in younger men. Younger females, again, aesthetically, may not want to deal with a stoma bag. So the Indiana pouch may be a little bit more popular with them because there's not a lot that you can, you can see on the outside, you can cover the opening up with just a small little Band-Aid or a little piece of tape, and a lot of times you can hide this opening in different areas. And they want to be dry, so this valve allows patients to be dry. And then when they're ready, they catheterize it to empty the urine.
Host Amber Smith: So for these bladder alternatives, if the muscle-invasive bladder cancer has already spread by the time you diagnose it, are these options for patients still available?
Joseph Jacob, MD: So in general, when we remove the bladder, we're trying to cure patients. So we're trying to prevent patients from having spread of disease. And so if someone already has spread of disease, usually they're not going to be a good candidate for removal of the bladder. To put someone through such a major operation, and probably it's not going to help them from a cancer standpoint, and you would delay them from getting the treatment that they need to get like systemic therapy or chemotherapy or immunotherapy. So usually if the bladder cancer has spread, then you're probably looking at mainly treatment with chemotherapy and immunotherapy.
Host Amber Smith: I was going to ask you to explain the possibility of bladder preservation. Are there other treatments for someone who has advanced bladder cancer, are there other procedures that you can recommend if someone really is against bladder removal?
Joseph Jacob, MD: Definitely. Definitely. We talk to patients about all their options and again, a lot of these options have been studied very well, so we have good data. Bladder preservation is a term used to describe patients that have muscle-invasive bladder cancer, and they, instead of getting their bladder removed, they get radiation with chemotherapy. And so it's a combination of radiation and chemotherapy. And patients can do very well with this. The reason why maybe a removal of the bladder is a little bit more common is because removal of the bladder is more definitive. But that doesn't mean that bladder preservation is a bad option. Patients just have to know what they're getting into. So when you do radiation to the bladder with chemotherapy, someone like myself, a urologist, would have to continue to really look at the bladder closely, do the camera procedures pretty often, do biopsies every once in a while just to make sure that the bladder cancer is not coming back.
So if you look at some of the big trials that were done for bladder preservation, about 70% of the patients were able to keep their bladders, but about one third of the patients did require removal of the bladder after the radiation. So, for some patients it was great for them. For some patients, unfortunately, they had to have their bladder removed anyways, after the procedure.
Host Amber Smith: Do you advise patients that they can try the chemo and radiation and have the bladder removal as a backup plan, so to speak?
Joseph Jacob, MD: So I give them their options, and I try to find out what their priorities are, what their goals are, if they're the type of patient that wants something definitive and just wants to get it over with, then maybe removal of the bladder is a better option for them. If they're the type of patient that is very averse to radical surgery, or sometimes patients may be worried about how they're going to do in a long operation, so, they may be a better candidate for bladder preservation.
Host Amber Smith: Well, I really appreciate you taking the time to explain all of this.
Joseph Jacob, MD: I appreciate you having me.
Host Amber Smith: My guest has been urologic oncologist Dr. Joe Jacob. He's director of the bladder cancer program at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, "The Healing Muse," with this week's selection.
Deirdre Neilen, PhD: Claudia Reder teaches at California State University at Channel Islands. Her poem "Brain Fog" attests to the hard work rehabilitation takes as a patient strains to return to her former state.
Between each read sentence,
I rest. I stare at my PhD dissertation
then copy the complex syntax of one sentence,
then substitute words. I imitate my former self,
mirror, the text with my new handwriting
sloppy as a ten-year-old's scrawl.
I think about Elizabeth Bishop's toucan
because I could use uncomplicated mirth,
and not think about the leak in the roof
which cannot be located, or the
sieve of my brain through which words fall
like tufts of feathers drifting off the planet.
Life collapses to one room surrounded
by books I love that I can no longer read,
my own Leaning Tower of Pisa.
Yet, having left the East Coast years ago
I can still summon the red sumac
when driving north on I-95, a mark of transition
between seasons and counties: the red berry talisman
letting us know we are nearer our goal,
it still grows on that bit of highway
and I am still driving by, hoping
for a glimpse of this berry,
hungry for something I can name.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air": what you need to know about hernia repair. If you missed any of today's show or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.