Is there a treatment that will work for both bladder cancer and MS, or at least not worsen the bladder cancer?

Question:
I have pre-existing low stage, non-invasive transitional cell carcinoma (found during investigations for MS). I have an employment history of chemical exposure that likely triggered both. I have been using Copaxone since diagnosis however my neurologist has asked me to step up treatment. The bladder cancer is immune mediated; for that reason, anything that suppresses my immune system will likely worsen the cancer. Is there an MS treatment that will somehow work for both, or at least not worsen the bladder cancer? I've seen that rituximab is used for some cancers however bladder cancer is not one of them. Any input would be really appreciated, even as a starting point for discussions with my neurologist and urologist. They don't have much experience dealing with both conditions. Thank you so much. My cancer is recurrent.

Answer:
You and your doctors will need to have a discussion of relative risks, specifically the risk of worsening your transitional cell carcinoma through the use of potentially unnecessary MS disease modifying therapies versus the risk of under-treating your MS. The only drug to definitely avoid is cyclophosphamide, which is associated with the development of transitional cell carcinoma. There was some initial concern that Tecfidera may be uniquely associated with transitional cell carcinoma but this is not a current concern and some are talking about studying Tecfidera as a treatment of cancer. Aubagio is not cleared by the kidneys and could be an option; it is easy to clear Aubagio out of your system quickly.
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Highly active DMTs that are selectively cytotoxic (Rituximab, Lemtrada, Ocrevus) may alter cytotoxic responses and immune regulation in negative ways but this would be a larger concern with Lemtrada. Tysabri is not cytotoxic and may be a good choice if you are JCV antibody negative and need a highly active drug.

I hope this helps you and your doctors with this decision.

Revere (Rip) Kinkel MD
Professor of Clinical Neurosciences
Director of the Multiple Sclerosis Program
Clinical Neurosciences Director
University of California San Diego