How to cure metastatic urothelial carcinoma in a 45-year-old?

Question

Hi doctor,

My 45-year-old sister was diagnosed with metastatic urothelial carcinoma eight months ago, and the treatment is really taking a toll, especially with her hormone levels being all over the place. She had a radical cystectomy with neobladder reconstruction, but now has terrible incontinence that affects her daily life and makes her feel like she cannot leave the house for more than an hour at a time.

Her oncologist started Pembrolizumab immunotherapy, but she is having these awful side effects, including thyroiditis, that made her TSH jump to 15.2 mIU/L, and now she is on Levothyroxine 75 mcg. The cancer has spread to her lungs and liver, and her CA 19-9 is 180 U/ml which keeps climbing. The worst part is that her menstrual periods stopped completely after chemo, and she is having terrible hot flashes, vaginal dryness, and bone pain that her doctor thinks might be from sudden menopause. She also developed neuropathy in her hands and feet, which makes it hard to work as a teacher. Her hemoglobin dropped to 7.8 g/dL, and she needs blood transfusions every three weeks now.

Can hormone replacement help with menopausal symptoms during cancer treatment? Are there ways to improve her quality of life while fighting this metastatic urothelial carcinoma?

Thanks.

Answer 1

Hi,

Welcome to icliniq.com.

I can understand your concern.

I am truly sorry to hear how much your sister is going through with metastatic urothelial carcinoma. It is already difficult, and the complications she is facing from surgery, immunotherapy, and treatment side effects are understandably overwhelming.

The sudden menopause brought on by chemotherapy can cause intense hot flashes, vaginal dryness, and bone pain, but unfortunately, hormone replacement therapy (HRT) is usually not recommended in women with active metastatic cancer, because estrogen and progesterone can increase the risk of clots and may complicate her oncologic treatment.

Instead, there are non hormonal strategies that can make a real difference: medications such as Venlafaxine, Gabapentin, or Clonidine can ease hot flashes; vaginal moisturizers and lubricants can help dryness and discomfort; and bone health can be supported with vitamin D, calcium, weight-bearing exercise when possible, and sometimes bone strengthening drugs like bisphosphonates or denosumab if her doctor feels they are safe.

For the neuropathy, medications such as Duloxetine or Pregabalin may reduce nerve pain, and occupational therapy can offer strategies to help her function as a teacher despite the numbness. Her anemia and transfusion dependence suggest that the cancer and treatments are affecting her bone marrow, and discussing supportive options such as erythropoietin-stimulating agents or palliative blood management may reduce the need for frequent transfusions, though these decisions must be individualized.

Importantly, a palliative care team, which is not the same as hospice, can focus on improving her quality of life right now, addressing pain, fatigue, mood changes, and the emotional impact of her illness, while her oncologists continue to treat the cancer. With the right support, she does not have to face these challenges alone, and her comfort, dignity, and ability to engage with her family and work can be prioritized alongside the cancer treatment.

I hope this information will help you.

Thanks.