Treating arthritis of the hands; HPV vaccine; bladder cancer surgical options: Upstate Medical University's HealthLink on Air for Sunday, Aug. 14, 2022

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an orthopedic surgeon discusses arthritis of the hands.

Brian Harley, MD: ... It's a little bit like some rust in our joints. And as that progresses, it starts to typically hurt, and then you start to get typically some stiffness. And then that's that arthritis that everybody starts rubbing their joints and complaining of that starts to make their lives more difficult or miserable at times. ...

Host Amber Smith: A pediatric infectious disease doctor explains how to protect against the human papillomavirus.

Manika Suryadevara, MD: ... It is a sexually transmitted infection that can go on to cause genital warts or, even more severely, new, different types of cancers. And it is the most frequent sexually transmitted infection in the United States. ...

Host Amber Smith: And a urologist provides some options for bladder reconstruction in patients with advanced bladder cancer.

Joseph Jacob, MD: ... 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 a hundred percent of the time, this will spread into the bloodstream and the lymph nodes. ...

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'll learn about the HPV vaccine. Then, a urologist goes over bladder reconstruction options for people with advanced bladder cancer. But first, an orthopedic surgeon talks about diagnosis and treatment of arthritis of the hands.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Today, I'm discussing arthritis of the hands, whom it affects and what can be done about it, with Dr. Brian Harley. He's an orthopedic surgeon who specializes in hand surgery and trauma reconstruction at Upstate.

Thank you for making time for this interview, Dr. Harley.

Brian Harley, MD: You're very welcome, Amber.

Host Amber Smith: Before we talk about treatments, I first want to ask you some basics about arthritis. Can you describe what it is?

Brian Harley, MD: Sure. It's a really common condition because we all have bones, and where the bones join together, there's things called joints.

And that's what allows us to be flexible and to move. And at the junction of these joints, there's cartilage, which is that smooth, fibrous tissue that you see when you're dissecting your turkey at Christmastime or whatever, and taking it apart. And those smooth surfaces are what allow us, our joints, to move so nicely and so well for most of our lives.

And what arthritis is, is that those smooth surfaces start to get rough. And it's a little bit like some rust in our joints. And as that progresses, it starts to typically hurt, and then you start to get typically some stiffness. And then that's that arthritis that everybody starts rubbing their joints and complaining of that starts to make their lives more difficult or miserable at times.

Host Amber Smith: So is this inevitable for all of us as we age, that we're going to get some degree of this?

Brian Harley, MD: Well, yes and no. Typically, our bodies are fragile, and over time, things do wear out, but there's definitely people that are more prone to get arthritis. So there's a genetic predisposition to it.

And then on top of that, there's people that may have injured themselves or a joint got roughened or traumatized during their youth or their young adulthood. And then that can, over time, degenerate.

So there's what we call primary arthritis, where you just genetically are predisposed to some things breaking down sooner.

And then there's post-traumatic changes, where there was some scuffing or injury that continues to deteriorate. So there's a couple of different ways to get it, and not every patient's arthritis is the same.

Host Amber Smith: Well, how common is it to show up in the hands, as opposed to some other joints?

Brian Harley, MD: Hands are quite common, mostly just because there are so many joints in the hand.

You only have one, well, two, hips, one on each side, whereas in the hands, you've got five fingers and 17 joints just in those ones alone, so there are some predispositions. So we know that in the hands specifically, women get arthritis moreso than men, especially at the base of their thumb and their fingers.

And so I see a higher population of women coming in with arthritis in their hands than men, but when men get it, the pattern is a little different. Women tend to get it more in the bases of their thumbs. Men get it at their, what they call their metacarpal-phalangeal joints, in their knuckles, there.

It's a variable presentation, and everybody's not predestined to get it, but we do see some trends.

Host Amber Smith: Why do you think it's different between men and women? Is it a function of how we use our hands differently?

Brian Harley, MD: No, it's probably just there's some theoretical concepts, and there's some reality.

Women tend to be a little more flexible than men. There's more laxity. And so when we examine thumb bases, especially, the way the joint is constructed, if it's really a little looser, then the cartilage can wear out over time sooner. So that's what we see. Typically, probably just some hormonal differences.

The sexes have some differences in our makeup, and then the way we use our hands, not really sure that's the case because I have people that come in and tell me they use their hands all their lives for different things, but the reality is everybody uses their hands for all their lives.

Some men are on jackhammers for 25 years, and they don't get thumb basal joint arthritis. So it's, like I said, some things are just predispositions to things. And then again, there's other genetic factors. And then just things that, some, we don't know.

Host Amber Smith: So is pain the only warning sign, or how would we know that we've got arthritis?

Brian Harley, MD: Everybody's presentation is a little bit different. I like to tell my patients that everybody's a snowflake, everybody's just a little bit different. Some people come in, and they have, on X-rays, really bad arthritis. I saw a gentleman yesterday in his early 70s, and his hands looked terrible on X-ray, but he tells me they feel pretty good, and he can do most things, and they don't look very good, but they still function, and they're a little stiff. Other people come in, and the X-rays don't look that bad, but they're very symptomatic, and they have a lot of soreness, and they have swelling. And so again, everybody's experience with their own pain is sometimes different, and the way their arthritis presents is different.

Host Amber Smith: So with someone who comes in with stiffness or pain or swelling, are there nonsurgical treatments that you start them on or that you recommend?

Brian Harley, MD: Sure. As a surgeon, people typically get to me after they've tried a lot of the nonoperative modalities, but mainstays, antiinflammatories, things like ibuprofen, Naprosyn, and then there are some other prescription anti-inflammatory medications. That's sort of the mainstay first treatment, and that's the things that, when we're 20 and 30, and we do too much on a weekend and things start hurting, we use those anti-inflammatories. And they're certainly the most effective, basic first treatment for arthritis.

When it progresses or when you're taking that regularly, and you're starting to get some breakthrough, then yes, there are some times braces or injections can be tried. Injections are typically what we call steroid injections. And they're just an anti-inflammatory steroid that we try to inject in or around the joint to do the same thing that the ibuprofen is doing, but just more in a concentrated form and right at a joint. Because when you take an anti-inflammatory by mouth, it diffuses through your whole body, and it doesn't necessarily get always where you want it. And so that's the advantage of an injection, but of course, an injection needs a needle, and some people don't really like those. Braces are sometimes used, but the problem with braces is the way they work is they prevent that joint from moving as much, which helps that roughness of the joint from causing the inflammation. But at the same time, our joints are meant to be moving. And once you start bracing, people's hands, for example, if you can't move your thumb as well, then you're less dextrous. And then there's often less you can do, so it might help with your pain a little bit, but then you can't be as functional.

So there's always that balance between what are we doing to try and help make your symptoms less, but not get in your way of doing what you want to during the day.

Host Amber Smith: This is Upstate's "HealthLink on Air." I'm your host, Amber Smith, talking with Dr. Brian Harley. He's an orthopedic surgeon specializing in hand surgery and trauma reconstruction, and our topic is treatment options for arthritis of the hand.

What types of surgery are options for treating arthritis of the hands or thumb or even wrist?

Brian Harley, MD: Sure. Well, all of those are kind of different sites. So I think we just would go through each one.

So, the wrist: It's a little less common to get primary arthritis in the wrist. It was often more of a post-traumatic arthritis. So people accumulate damage from some wrist sprains and falls, and just minor trauma that over time builds up. And then, you start to see some arthritis in the wrist. And when that happens, sometimes some bracing works. And then if you start doing surgery for the wrist, then that's often some pretty big surgeries where you have to start either removing bones or fusing bones together.

And then that fundamentally changes the way the wrist works. So wrist arthritis sometimes can be a bad one just because it's going to change. I have, especially in men who are in their 50s and working and doing labor-type activities, once we start doing surgeries on that, it's time to get out of the labor pool sort of thing and get a desk job sort of thing. So wrist arthritis can be a bad one.

In the hand, the thumb, as we talked about, very common for women, and so we do have some surgeries for that, where we can really restore motion and just take out the little bones that have worn out and give them a pretty functional thumb, and they can maintain a lot of things that they do.

Brian Harley, MD: So the thumb is a really common surgical site, and we have some really reliable surgeries for that, that have really been time tested.

And then as you move into the hand, then out into the fingers, there's a variety of different options for that. Sometimes you can just clean a joint out and do a fusion.

So out at the distal end, at the fingertips, if the arthritis was really bad there, you don't have a lot of motion if we just fuse the joint together, which is just to scrape those surfaces out and put it together, then that takes care of the pain, and the hand can be very functional.

As we get into the first and second knuckles of the finger, those have a lot of motion. And so those are sometimes challenging because sometimes people have some pain, but their motion looks really good. And then you don't want to go in and do fusions or joint replacements because they'd actually be better off with what they've got. So, especially in that central part of the hand, spend a lot of time just doing value judgment and really pressing the patients to decide: Is this bad enough that we start having to remove parts of them, or can they live with it longer? Because often living with it longer is actually the best thing.

Host Amber Smith: So it sounds like you need to really talk with the patient about what their goals are and what they want to be able to do with their hands.

Brian Harley, MD: It absolutely is. The most frustrating arthritis for most patients is the ones where they have pain, but they have still a lot of motion left because that's the challenging ones. Some of the easiest arthritis patients are the ones where the pain is significant, but the joint's gotten really stiff on them. Because then when you either do a fusion, which takes away their pain, or you offer them a joint replacement, which restores some motion, then that's a real bonus for them.

So the patients that just come in with: It's sore and it's swollen, it really slows them down, but really their hand looks and functions pretty well, those are the most challenging patients.

Host Amber Smith: Is there ever concern about whether a person is actually a candidate for surgery, or would most patients be candidates for this type of surgery?

Brian Harley, MD: Yeah, again, it depends. The risk is more major surgery out in the fingertips. Sometimes it's just the last knuckle; those can be done under almost local anesthesia, if there's little surgeries for that. So yes, and especially we do see more elderly patients, that often have more health problems, and so you do have to obviously take that into consideration, but the good news is, especially operating on people's extremities, even if I need a general anesthetic, because you're operating on their hands, there's not as much risk even with a general anesthetic. So in most cases, there's low risk from surgery.

Host Amber Smith: What is recovery like?

Brian Harley, MD: Again, totally depends upon the surgery, but in most cases, it's six to 12 weeks of a typical recovery of the initial postoperative pain. And then usually there's a splinting involved. And then in most cases, especially with the hand, because you're trying to get back motion, there's a degree of physical therapy involved for a month or two.

And then most people, by two or three months, for most of these surgeries where they're either taking out little parts of their bones or putting a little joint replacement in, or even fusing it and the bone starts to heal, by two to three months, most people are usually pretty happy that they're on the road to recovery.

Host Amber Smith: So if someone undergoes a joint replacement or a fusion, how common is it for arthritis to return to that area? Do you ever see that?

Brian Harley, MD: The surgeries that we are doing, so you just take one finger joint, and whether you do a joint replacement or whether you fuse it, that permanently removes the problem, because the joint has essentially been resected, whether you fuse the two surfaces, which means you cut out the cartilage and put the two bone surfaces together, so they knit themselves into one bone. Then you can't have arthritis, because there's no motion, and there's no joint. If you do a joint replacement, similarly, the joint has now been resected in some sort of polymer or metal, and plastic has been put in to replace it. The problem with the joint replacements is those are artificial materials that obviously can break down and wear out over time, but the actual arthritis is gone because the joint has been removed.

Host Amber Smith: If a person has severe arthritis in one hand, how common is it for them to also have the same problem in the other hand?

Brian Harley, MD: Again, it somewhat depends upon the underlying cause. So if somebody just has a primary osteoarthritis from a genetic predisposition, then it's very common, it's usually very symmetric. If you take an X-ray at one hand, the other hand very much looks similar, even though one side may be more symptomatic, the X-rays are often similar. If it's a post-traumatic thing, where they injured themselves at an earlier time in their life, and then over time things have deteriorated, then obviously sometimes it can be localized to one side or one area.

Host Amber Smith: As an orthopedic surgeon, specializing in hands, do you offer alternatives to joint replacement or fusion operations?

Brian Harley, MD: Not really. I mean, as a surgeon, those are our standard surgeries. There are other holistic things and other things available for people out there, but mainstream medicine and science-based medicine, typically, is working with anti-inflammatories and nonoperative modalities as much as we can. And then. when things have gotten to the point where they're not being controlled with those methods, then standard, time-tested and scientifically proven surgical alternatives are what I focus on, more or less.

Host Amber Smith: I've read about research into using stem cells to help regenerate damaged joints. But how soon might that be a reality?

Brian Harley, MD: You know, that's really uncertain, Amber. I remember when I was a resident (training to be a surgeon), which I'm starting to date myself, but that was in the mid-90s, and one of my mentors was doing some basic science research on just cartilage regeneration, and that was over 25 years ago, and they were doing it in an animal model. And so we know a lot more about cartilage than we did 25 years ago, but other than still growing it in a Petri dish and in a lab, we're not at the stage where in any sort of reliable fashion can we inject that into a joint and then have it be long-standing or any sort of a replacement. Some of that's just, the physiologic genesis of all of this, is just, typically the cartilage is wearing out, and we just don't have a solution to some things wearing out, much like our cars rust in the winter in Syracuse, there is some just natural deterioration that's going to occur.

Host Amber Smith: Before we wrap up, how do you help someone decide what treatment is best for their particular situation?

Brian Harley, MD: Again, that's just patient education as much as possible. You try and explain, and different people have different levels of understanding, and some people really want to get to the basic science understanding, and some people just say, "Please, doctor, just tell me what's best, and then we'll go with that. So working with the patient, trying to educate them to where they feel comfortable and then be realistic and telling them what the outcomes can be. Because as we talked about wrist surgery, we generally don't have a perfect solution. We're trying to find something that helps them and makes them more functional, but isn't necessarily going to be a revolution and life changing.

Whereas with thumb arthritis for that 60-year-old lady, her thumb is totally burnt out, a thumb arthroplasty option can be just a wonderful option that just makes them pain-free and very functional again. So just being realistic with patients, to say, "Hey, this is either really, really, really good, we should really go this route," or "Listen, you have to make a value decision here, as I can help, I can make this better, but we're not going to make it perfect." And so that's the challenge for me, is to help people understand that decision process.

Host Amber Smith: Well, thank you so much for making time for this interview.

Brian Harley, MD: You're very welcome.

Host Amber Smith: My guest has been Dr. Brian Harley, an orthopedic surgeon specializing in hand surgery and trauma reconstruction at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air. "

What's important to know about the human papillomavirus -- 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 human papillomavirus, or HPV, can cause genital warts and cervical cancer, but there is a vaccine available. Here with me to talk about HPV is Dr. Manika Suryadevara.

She's an associate professor of pediatrics at Upstate, where she specializes in infectious disease. Welcome to "HealthLink on Air," Dr. Suryadevara.

Manika Suryadevara, MD: Thank you for having me on to speak about this very important cancer prevention vaccine.

Host Amber Smith: Please tell us about HPV. What is this virus?

Manika Suryadevara, MD: HPV is the human papillomavirus, and it is a sexually transmitted infection that can go on to cause genital warts, or, even more severely, new, different types of cancers.

And it is the most frequent sexually transmitted infection in the United States. It's actually so common that almost every individual who is unimmunized will acquire this infection at some point during their life.

Host Amber Smith: I didn't realize that. So it's more common than herpes or gonorrhea?

Manika Suryadevara, MD: It is. So at any point in time, there are about 40 million people with an HPV infection. The next most common sexually transmitted infection would be herpes at 19 million infections, so you can see how frequent this virus infection really is.

Host Amber Smith: So how many different types of HPV are there, and is there only one that causes cervical cancer?

Manika Suryadevara, MD: So that's a great question. There are over a hundred different types of HPV and then over 40 of which can infect the genital area. And by infecting the genital area, that could mean multiple things. These viruses have been stratified based on their risk for developing into cancers. So you can have low-risk HPV, which more commonly causes the genital warts, or you can have the high-risk HPV.

And those are more likely to go on to cause cancers, not just cervical cancer, even though that's the association we make, but any sort of genitourinary cancers. So that includes penile cancer, anal cancer, and it also can cause a head and neck or a throat cancer.

Host Amber Smith: Do you see HPV infections in children, or is it mostly young adults, or is it older adults?

Manika Suryadevara, MD: There are about 13 million new HPV infections that occur each year in the United States. And more than half of these infections are occurring in our young adult population. So that's typically people between the ages of 15 to 24 years old. Now, most of HPV infections are asymptomatic.

So that means that most people in the United States who are infected with HPV don't even know that they have infection. This infection may or may not clear itself from the body without any intervention or even knowledge that there was an infection. The HPV infection that persists, however, can stay in the body for years and ultimately go on to develop cancer.

So while the infection can be acquired in the young adult period, it is most often manifested with these cancers later on in life.

Host Amber Smith: So there's no reliable symptom that people get,so most people wouldn't even necessarily know they're infected? Is that right?

Manika Suryadevara, MD: That is correct. So if someone were to develop genital warts, that would be an indication that they probably have an HPV infection.

For cervical disease, there is a screening method. So women who are getting their Pap smears, can be identified to have abnormal cells that may be due to HPV infection, but outside of that, HPV is often diagnosed at the time of cancer diagnosis, particularly for throat cancer and noncervical disease.

Host Amber Smith: Would a doctor diagnose HPV if there were genital warts, or is there a way to do that when you see genital warts?

Manika Suryadevara, MD: Genital warts is most often caused by HPV infection.

Host Amber Smith: So it's assumed that if you have the warts, that's probably why.

Manika Suryadevara, MD: Exactly.

Host Amber Smith: Now I think you kind of described this: Once a person's infected, does their body just fight it off and it goes away, or does it stay in the body?

Manika Suryadevara, MD: Most often when a person is infected with HPV, the body fights it off, and the infection gets cleared, and there's nobody even knows about it. However, there is a substantial proportion of infection that stays in the body, and it is the virus that stays in the body that leads to cancer development.

And when we're trying to just see how much disease burden that really means, you can look to see the data regarding HPV cancers, and each year HPV has been found to be responsible for 35,000 cancer cases in the United States. It is the major cause of cervical cancer, penile cancer, vaginal cancer, anal cancer and throat cancer.

And in fact, HPV causes 70% of mouth and throat cancers in the United States now, so where we used to associate mouth and throat cancers with smoking and alcohol, now HPV causes most of them.

Host Amber Smith: And is that through sexual contact usually?

Manika Suryadevara, MD: Correct. That is through sexual contact.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Manika Suryadevara. She's an associate professor of pediatrics at Upstate, specializing in pediatric infectious disease. And our subject today is HPV, the human papillomavirus.

So let's talk about treatment and prevention. Can HPV be cured if someone develops it?

Manika Suryadevara, MD: There's no antiviral treatment to get rid of the virus, so treatment of HPV really is based on the symptoms that are presenting. So individuals with HPV genital warts can see their doctor to see if there's any ways to reduce the warts, and those with HPV cancers should be followed by their providers and may need chemotherapy or surgery or radiation for treatment.

But there is no medicine to remove the HPV from the body. What we can do is we can prevent infection, and the best way to prevent infection is the HPV vaccine.

Host Amber Smith: So tell me more about the vaccine. How does it work?

Manika Suryadevara, MD: So the HPV vaccine, the one that we currently are using in the United States, is 9-valent, which covers for the majority of HPV types that are causing cancers today.

And essentially the vaccine is recommended to be given at the 11- to 12-year-old well-child check. And, you know, you hear 11- and 12-year-olds, and you think, oh, why are we giving them the vaccine this early? And there are multiple reasons for doing so. There is definitely rationale for doing that. The first reason is because at the 11- to 12-year-old well visit is when these teens are getting other adolescent vaccines, their tetanus shot for school, their meningitis shot, so it really fits into the adolescent vaccine platform. A second, very important reason to vaccinate at the 11- to 12-year-old visit is because we know that younger adolescents produce a much stronger antibody response to the vaccine, compared to older adolescents. And this is why when you get the vaccine, when you're a younger teen, so 11 or 12 years old, you only need two doses of the HPV vaccine series.

Whereas if you get the vaccine after your 15th birthday, you need three doses of the vaccine series to get the same response. So it's really recommended to start at the 11- to 12-year-old visit and can even be given down as young as 9 years of age to get these kids immunized and protected.

Host Amber Smith: Now you mentioned kids, boys and girls. Cervical cancer only affects women, though, so why are the boys being vaccinated?

Manika Suryadevara, MD: So again, while we consider HPV vaccine to really protect against cervical cancers, essentially it's protecting against all HPV-associated cancer. And if you look at mouth and throat cancer, men are at higher risk of acquiring HPV throat cancer than women.

And men can also develop penile cancer due to HPV. So by vaccinating boys and girls, you are protecting both genders from developing HPV-associated cancers later in life.

Host Amber Smith: I don't think a lot of people realize that a vaccine exists that can prevent cancer. Does this surprise people when you explain this to them?

Manika Suryadevara, MD: It does surprise people because when we think of HPV, we think of it being a sexually transmitted infection. But the whole goal of vaccine really is to prevent these cancers. You know, 4,000 women are dying each year from cervical cancer, and that's with screening and with treatments. And here we have a vaccine that can prevent infection and the subsequent development of cancers in our sons and our daughters.

So I think it's a very important message to send that we're really trying to prevent cancers in our teens by giving the HPV vaccine. Now the HPV vaccine, while it can be started around 11 to 12 years of age, is recommended all the way through 26 years of age for everybody. And then for adults who are between the ages of 27 and 45, if they are considered themselves to be at higher risk for acquiring HPV infection, they can talk to their provider and discuss whether they should also be vaccinated.

Host Amber Smith: I wondered because there's a lot of people who, you know, this vaccine wasn't available when they were adolescents. So in general, can people who are older than 21 get vaccinated?

Manika Suryadevara, MD: Recommendations for a routine vaccine or HPV series go all the way through 26 years old. So if you're an individual who's 24 years old and has not been immunized against HPV, definitely speak with the provider to get vaccinated. And then adults who are 27 through 45 can talk to their provider about risk factors and the benefits and risks of getting vaccinated.

Host Amber Smith: What about people in their 50s, 60s and older? Do they need HPV vaccines?

Manika Suryadevara, MD: Currently guidance goes up through 45 years of age, where there's universal routine recommendations for administration of vaccines as early as 9 years old, all the way through 26 years old. And then for adults 27 through 45, it's based on an individual case, discussing benefits of the vaccine.

Host Amber Smith: Is that because of the time it takes for the cervical cancer to develop?

Manika Suryadevara, MD: Correct. Any kind of HPV-associated cancer, the older you are in life, the less likely it is you are to be exposed to the virus, and the vaccine works best prior to exposure to the virus as opposed to once infected. So the recommendations really are to capture everybody who's younger and at risk of newly acquiring HPV infection. And that's where the focus is.

Host Amber Smith: If people got the vaccine as children, are they going to need boosters later on in life?

Manika Suryadevara, MD: As of right now, no boosters are recommended or needed. We have over 10, 15 years' worth of data showing significant antibody response and significant reduction in HPV disease. We're talking about genital warts and cervical precancers as well as cancers associated with HPV in the vaccinated population. So no booster doses are needed, and we have a lot of safety and efficacy data showing that even 10, 15 years later, the vaccine is working very well.

Host Amber Smith: If someone has already been infected with HPV before they're vaccinated, is the vaccine going to have any protection for them?

Manika Suryadevara, MD: Yes, so it is very important if someone has been already infected with HPV to get the HPV vaccine, because it is likely that they were infected with only one type of HPV, and the HPV vaccine prevents against nine types of the virus. So to ensure that they stay protected from future infections, it is very important that even if an individual has been infected in the past, that they do go and get the HPV vaccine.

Host Amber Smith: What if you have a couple -- partners -- that are never with anyone else; are they at risk for HPV in other ways?

Manika Suryadevara, MD: The risk factors for developing HPV-associated disease, as you mentioned, earlier onset of sexual activity, multiple partners, I would say, to be fully protected even though you are solely with one other partner, my recommendation for everybody, because we know it is a safe and effective vaccine that does prevent cancer, my recommendation to everybody is to get vaccinated.

Host Amber Smith: Has the vaccine been in use long enough to have an impact on reducing the number of cervical cancers or genital wart cases?

Manika Suryadevara, MD: Yeah. So we have over 15 years' worth of data on vaccine safety and efficacy, and there are multiple studies coming out, showing significant reduction in HPV infection, genital warts, precancers and cancers in the U.S. and in other countries around the world with robust HPV vaccination programs.

Host Amber Smith: Are there other vaccines that are designed to protect against other cancers?

Manika Suryadevara, MD: Yes. So the main one that comes to mind is the hepatitis B vaccine. Hepatitis B virus can be acquired, again, through sexual transmission or through contaminated blood exposure. And we know that chronic hepatitis B virus also leads to liver cancer. Now we have a hepatitis B vaccine that's been in use for quite a while, currently given to infants in the first 6 months of life, but then can be administered to, any unimmunized individual at any age to prevent the acquisition of hepatitis B virus, and the subsequent development of liver cancers.

It's a very similar purpose of, here we have a vaccine that prevents liver cancers, and we routinely vaccinate all our newborns with it, and anyone who's older who has not been unimmunized again for the sole purpose of cancer prevention.

Host Amber Smith: Well, thank you. I really appreciate you making time for this interview.

Manika Suryadevara, MD: Well, thank you for having me.

Host Amber Smith: My guest has been Dr. Manika Suryadevara, an associate professor of pediatrics at Upstate, specializing in pediatric infectious disease. I'm Amber Smith for "Upstate's HealthLink on Air."

Next on Upstate's "HealthLink on Air" -- bladder reconstruction options.

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, so 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 a 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 a 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 ilium, 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 esthetic 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 ilium, 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 surveilled 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 Bandaid 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's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Laura Carroll from Washington, DC, writes about food, travel and fairy tales. She sent us a unique take on grief and how to handle it in her prose piece "Recipe for Lemon Cupcakes":

1. Take your grief. Form it into a small ball in your hands.

2. Zest a lemon or three or five. There are so many in your mother's kitchen, and you have to do something with them. They can't just molder in the fridge.

3. Chop the lemons and put them in a saucepan with sugar and water. Boil. Stir. Simmer. Stir more. It will eventually turn to marmalade

4. Add your grief to the marmalade. It's already bitter. It can take it.

5. Measure out your dry ingredients in a bowl, mix, and set aside.

6. Beat up defenseless eggs, and butter and sugar until light and fluffy. Add vanilla extract and lemon zest, and beat again.

7. You forgot to preheat the oven, didn't you? Turn it on now.

8. Add the dry ingredients to the wet ingredients in batches, mixing thoroughly and scraping down the sides with a spatula after each addition.

9. You have a cupcake tin somewhere, don't you? Find it, along with the leftover cupcake papers from several Halloweens ago. The ones with skulls.

10. Spoon the cupcake batter into the tin until each papered cup is half full. Carefully place a spoonful of marmalade in the center of each cupcake, then cover with additional batter.

11. Bake for 20 minutes at 350, or until a toothpick inserted in the center of a cupcake comes out clean except for the marmalade.

12. While the cupcakes bake, raid your parents' liquor cabinet. Pour yourself a glass of the single-estate cognac that your father never had the opportunity to drink, and bring the limoncello to the kitchen.

13. Beat up another defenseless stick of butter to make the frosting, and add more powdered sugar than you think the butter can hold. Keep beating it until it's mostly incorporated, then add a liberal dose of limoncello and watch the alcohol smooth out the frosting as you continue to beat.

14. Remove the cupcakes from the oven. Allow to cool.

15. Improvise a pastry bag from a Ziploc sandwich bag. Pipe the limoncello frosting onto the cooled cupcakes.

16. Share the finished cupcakes with your assembled family. Everyone agrees that they are delicious. No one comments on the bitterness of the marmalade inside.

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": is there a link between herpes and Alzheimer's?

Host Amber Smith: 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.