Recurrent Bladder Cancer in a Teenage Male - Beyond the Abstract

There is a growing population of pediatric, adolescent, and young adult patients with urologic genitourinary (GU) malignancies. These patients face unique issues beyond cancer diagnosis and treatment, such as infertility, radiation exposure both during therapy and for long periods of surveillance, the risk of developing a secondary malignancy decades after oncologic cure, the long-term impacts of chemotherapy, and the psychosocial burdens of malignancy. Unlike in older patients who have completed families and already have pre-existing medical conditions, these issues often rightly play into counseling of and treatment decisions for young patients. 

While less publicized than pediatric oncology, there are actually more teenagers diagnosed with urologic malignancies each year than children and in general, outcomes are worse than their pediatric and adult counterparts. While there are likely a number of factors at play, such as decreased clinical trial participation, these patients are often at the transition phase between adult and pediatric medical worlds. Similar to patients with neuropathic bladder, this transition period very likely contributes to things “falling through the cracks.” But this should never happen, given the unique perspective that that pediatric urologist adds. 

As pediatric urologists, we have all been trained in adult urology first before specializing in urologic issues more commonly seen in children. In some ways, we treat patients of all ages, from before the cradle all the way up to adulthood, where there can be an interplay with more “adult” issues. We have to be experts at both and draw knowledge from all aspects of our experience and training. This is especially true with respect to oncology, where cancers are commonplace and very well studied by our adult urology counterparts. A simple glance at the American Urological Association (AUA) publications shows that our adult colleagues have studied and published a number of excellent, evidence-based guidelines for the majority of urologic cancers in adults. There is no reason that we cannot borrow from the experience as it may apply to our pediatric practices when other pediatric-centric guidelines are lacking or simply do not exist. 

While there have been major advances in treating pediatric GU malignancies, namely Wilms tumor and rhabdomyosarcoma, there are certain GU tumors that occur so rarely in children that prospective, randomized trials are not feasible. There are also significant advances that have been made on the adult side, namely in testicular germ cell tumors, which have yet to be fully incorporated in the pediatric realm. Pediatric urologists, therefore, are positioned at the ideal intersection between knowledge and advances in adult GU cancers (such as bladder, testis, and renal malignancies) and both the knowledge of pediatric GU cancers and the unique perspectives and thoughts of late effects from the pediatric side. It is crucial that we are able to wear multiple hats to triage and help our patients, no matter what their age or pathology. We have so much data available to us, we just have to examine it from all angles to extract the knowledge and experience to maximally benefit our patients. 

Written by: Amanda F. Saltzman, MD, Assistant Professor of Urology, Department of Urology, University of Kentucky, Lexington, Kentucky, Twitter: @urosaltyMD

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