Meredith Donahue:
Hello, and welcome to this Virtual Roundtable on what advanced practitioners need to know about non-muscle invasive bladder cancer. My name is Meredith Donahue. I'm a nurse practitioner at Vanderbilt Urology, specializing in urologic oncology. Joining me today for this discussion are Zuzana Lacca and Jennifer Gomez. Would you all like to introduce yourselves?
Jennifer Gomez:
Hi, I'm Jenny Gomez. I am a physician assistant at UC San Diego Health, and I run our bladder cancer survivorship clinic.
Zuzana Lacca:
And hi, my name is Zuzana Lacca. I work at Walter Reed. I'm a nurse practitioner there, and I specialize in GI/GU cancers.
Meredith Donahue:
Perfect. Thank you all so much. Let's start with getting into it. Jenny, do you want to get us started?
Jennifer Gomez:
Yes. Today we're here to discuss the rapidly evolving landscape of non-muscle invasive bladder cancer, particularly high-risk disease. Super exciting time in bladder cancer care, because we've seen an expansion of all the different treatment options and a shift in how we approach patient management. With these advancements comes an increasing need for multidisciplinary collaboration. And I think today we're going to explore the treatment landscape, how it's changing, and how urology, medical oncology, advanced practice providers, pharmacists, we can all work together to optimize patient outcomes.
Meredith Donahue:
Great. Well, let's start getting into the evolving care pathway and high-risk non-muscle invasive bladder cancer.
Jennifer Gomez:
Yes, so I think the first thing we have to define is who is high risk. So, after you diagnose someone with bladder cancer, we do separate them into risk categories. Someone who is high risk has high-grade T1 or they have CIS or certain pathologic features that categorize them as high risk.
Meredith Donahue:
Yes, I really like your point that before we can do anything, we have to define the disease. Because bladder cancer is so confusing with all of the high-grade, low-grade, staging, etc. And before you can treat, you kind of have to understand the risk stratification, because that drives everything we do.
Jennifer Gomez:
And it does matter as well, because patients with high-risk disease do have a higher risk of recurrence and higher risk of progression, so we want to make sure we're identifying these patients and treating them appropriately.
Meredith Donahue:
Yes, absolutely.
Jennifer Gomez:
So initial management of high-risk bladder cancer of course involves a high-quality TURBT. Sometimes if you are not able to get muscle on the initial specimen, it is really important that we have a high-quality TURBT, possibly a repeat TURBT to make sure that muscle is in the specimen and we make sure that this is not muscle-invasive disease. Typically, for high-risk non-muscle invasive bladder cancer, the initial recommendation is to start with intravesical BCG, an induction course followed by maintenance treatment when appropriate. This is then followed by cystoscopic surveillance where we check and manage for recurrence.
Meredith Donahue:
And how often typically are you doing these surveillance cystoscopies in the office and scans?
Jennifer Gomez:
Yes, so every three months, every three months for the first two years for cystoscopy, and then scans, everybody gets a set of staging scans at diagnosis to check for metastatic disease, so CT chest and a CT urogram. And then typically for these patients, if they're very high risk, we'll check a set of scans about once a year.
Meredith Donahue:
Yes. Usually six months to a year I think for those high risk patients.
Jennifer Gomez:
Yes, depending on what we're seeing in their bladder.
Meredith Donahue:
Right, exactly.
Zuzana Lacca:
Are you involved in medical oncology now?
Jennifer Gomez:
Our approach at my institution is we have a multidisciplinary tumor board where we present all our high-risk patients, particularly to have a discussion with a medical oncologist, a radiation oncologist, and a urologic oncologist. Actually, we have the whole bladder cancer team. So, our nurses are present, our advanced practice providers, and we work together to make sure we're optimizing their treatment pathway and make sure everybody has a say. I think that multidisciplinary care is so important in these bladder cancer patients. Everybody has different quality-of-life issues with their bladder cancer treatment and different priorities, and I think it's important to not fit everyone in a box and to do our best to personalize care for everybody.
Meredith Donahue:
Yes, I totally agree with that. As much as one-size-fits-all sounds amazing, it's just not that. And every patient is so different, and I think it's important to note that we know bladder cancer is one of the most costly cancers among all cancers. So, just remembering that and keeping that in mind that it is both most costly and most timely for patients with all of the treatments and scans and surveillance that it requires, especially in that NMIBC.
Jennifer Gomez:
Yes. Even thinking about having to come to the office every three months for a cystoscopy, procedures are expensive and that is a huge time burden for our patients and can be very challenging. It's a very exciting field right now and it is super important as providers that we help our patients navigate this field, because there are so many new treatment options available. So, not only do we have BCG, we also have so many other new intravesical and systemic therapies that can be used to treat high-risk disease. So, it's very important to help our patients navigate this ever-evolving field of bladder cancer.
Meredith Donahue:
Yes, absolutely. It's hard for us to keep up.
Jennifer Gomez:
Yes. So, some of the unmet needs of bladder cancer patients are kind of finding durable bladder preservation treatments, timely identification of recurrences, and what we do when they're unresponsive to our initial therapies like BCG.
Meredith Donahue:
And if they're BCG unresponsive, when might you refer to medical oncology vs continuing with urology?
Jennifer Gomez:
I think for me, we typically refer to medical oncology for BCG non-responsive patients who have a very difficult time holding the medicines in their bladder, but also prefer bladder-sparing treatment, that is a cohort of patients that could potentially benefit from systemic therapy like immunotherapy.
Meredith Donahue:
Yes, absolutely.
Jennifer Gomez:
In your practice, how do you guys handle that?
Meredith Donahue:
I mean, with the NMIBC patients, I mean, we really hang on to them, unless they're getting systemic therapy with an IO. Otherwise, the medical oncologists have let us take this and run with it. Really trying, if bladder sparing is a priority for the patient, then really trying to get them through the intravesical therapies to tolerate them and to tolerate the therapies. And if they're having a hard time holding them, doing everything we can to help them hold their treatments and get through it to hopefully give them the best outcome, which for certain patients that might be keeping their bladder.
Jennifer Gomez:
Yes, we operate very similarly. We really try to optimize their intravesical therapy and get them to tolerate treatment as much as we can and manage their side effects so they can keep their bladder.
Meredith Donahue:
Yes. And who knows? I think the landscape, like you've already said, is changing so rapidly that this is becoming much more of a multidisciplinary care with using both intravesical therapy plus systemic therapy looking or talking specifically about BCG plus durvalumab from the POTOMAC trial. So, the tides might be changing, but if anything, it's just going to provide more care for these patients.
Jennifer Gomez:
Yes. I think for immunotherapy it's super from a urology perspective because we do have so many intravesical options. It's very important to make sure we're doing appropriate patient selection and selecting patients that could truly benefit. Nothing's a free ride, unfortunately, when it comes to bladder cancer. Every treatment comes with its side effects.
Meredith Donahue:
Okay. Let's talk about a case study. So, we have a 60-year-old male with a history of high-grade T1 with CIS, BCG unresponsive. So, he got induction BCG once a week times six, and then he got reinduction times six, however, still had persistent disease. He then got pembrolizumab. However, this was discontinued after one dose due to an immunotherapy hepatitis. Jenny and Zuzana, any thoughts on what maybe some next options could be?
Jennifer Gomez:
Cystectomy is always on the table. It's always something we have to talk about. We know it has the highest risk of cure. And then there are some newer intravesical options that we can also discuss.
Meredith Donahue:
Yes, I think your point is fantastic. This patient felt really strongly about keeping his bladder. So, he got induction gemcitabine plus docetaxel and was disease-free after induction, went on to maintenance, and unfortunately did have a recurrence. But your point about the cystectomy is a really good one. I think we've all probably heard of the CISTO trial, which was a prospective patient-reported multicenter observational cohort study just comparing radical cystectomy vs bladder-sparing therapies in patients with recurrent high-grade NMIBC. And I know I was surprised that those results came out pretty equal. What did you all think about those results?
Jennifer Gomez:
We do know that cystectomy has a higher rate of cure, but it does also come with a lot of quality-of-life concerns. So, it's not always the best decision for every patient, but it is something that we should be discussing with our patients along the way, so everybody knows all their options.
Meredith Donahue:
Yes, I agree. I think bringing up cystectomy early and often, that option is there, and every patient is going to have a very different goals. Their goals of care are going to be really different. And some it might be absolutely to keep their bladder. Some it might be, "I want to get this over with."
Jennifer Gomez:
Yes. Some people have been through so many intravesical treatments that actually their lower urinary tract symptoms are so bothersome that a cystectomy is their preferred option. And then on the flip side, you also have patients who would do anything. They want to try everything that we have underneath the sun before we take out their bladder.
Meredith Donahue:
Yes, absolutely.
Zuzana Lacca:
I think as you said, and it's just that it goes to patient goals of care and preferences, and I feel like that it has to be really important for early on having those conversations and continuing them after each treatment that perhaps didn't go according to their expectations where they relapsed, then just investigating again what it is that, first of all, is feasible to do and what it is that it's important for them to do.
Meredith Donahue:
Yes. And Jenny, back to our patient, you mentioned he has so many intravesical options to choose from. And it's interesting talking about this patient now who is well known to me. This was probably three years ago or maybe four years ago, and it's pretty crazy to think about how much the landscape has changed even since this time that he received these therapies.
Jennifer Gomez:
Yes. The case is really interesting, especially since he had BCG-unresponsive disease, but he did respond well to a chemotherapeutic agent in his bladder. And I think that that is an amazing emerging area to new biomarkers, new information to help tell us which therapy might work a little bit better.
Meredith Donahue:
Yes, that's such a good point, and good point for us as a community to just be thinking about of who responds to what and why. And like you said, utilizing these newer biomarkers to get patients the right treatment for them.
Meredith Donahue:
I think that just about brings us to the end of this discussion. Please see our other two videos for further discussion on non-muscle invasive bladder cancer at JADPRO.com.
