Non-Muscle Invasive Bladder Cancer in Transition: Coordinating Care as Systemic Therapy Enters Earlier-Stage Disease

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 Health, specializing in urologic oncology. Joining me today for this discussion are Zuzana Lacca and Jenny Gomez. Would you all like to introduce yourselves?

Jennifer Gomez:

Hi, I'm Jenny. I'm one of the PAs 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 in Bethesda, Maryland, and I specialize in GI/GU cancers and medical oncology.

Meredith Donahue:

Perfect. Thank you both for being here. And I'm going to get us started by talking about practical approaches to care coordination for patients with non-muscle invasive bladder cancer.

So given who we are and what we do, I'm really going to kind of focus on the advanced practice provider's role in non-muscle invasive bladder cancer. And I think APPs play a bigger role now more than ever with so many, or it's such a rapidly evolving landscape with so many new therapies. This is exactly where APPs can thrive. I think I want to touch on at least about APP-led intravesical therapies and what is the APP's role both before, during, and after intravesical therapy because the APP has a role in all of those.

And lastly, what does side effect management look like in non-muscle invasive bladder cancer with intramuscular therapies? Just looking at BCG itself, about 70% of patients develop lower urinary tract symptoms while getting BCG, and about 7% to 20% have to discontinue treatment due to side effects and toxicity. So let's get into all of that.

So first, I want to start with what does the APP's role in non-muscle invasive bladder cancer look like before the patient even starts therapy? I know a big part for me in managing these patients is actually assessing and treating baseline lower urinary tract symptoms prior to starting therapy. If someone has frequency and urgency before they start treatment, we know that's only going to get worse. At your institutions, is there any protocol or plan for trying to get ahead of some of those side effects?

Jennifer Gomez:

Yes. Just making sure you do the baseline assessment and assess their voiding before. For men with non-muscle invasive bladder cancer, they also have BPH and that can worsen their urinary symptoms with BCG treatment. Women postmenopausal are super susceptible to the GU syndrome of menopause, also to recurrent urinary tract infections. And so really important to assess for all of those things at baseline before we start these intravesical treatments.

Meredith Donahue:

Yes. You mentioned one of my hills I'll die on, which is transvaginal estrogen cream in postmenopausal women with non-muscle invasive bladder cancer, for sure.

Jennifer Gomez:

Yes. I actually have transitioned to getting almost every prescribing vaginal estrogen for almost everybody unless they have a personal contraindication or where they don't want to take it, but almost for everyone gets vaginal estrogen.

Meredith Donahue:

Yes, absolutely. And then also trying to get ahead of the lower urinary tract symptoms, but also there can be a lot of systemic side effects from BCG. So if I have a patient who we know that they have fevers, chills for the first 48 hours after treatment, then I can make a plan with them to, all right, let's start alternating Tylenol, ibuprofen the night before you come in and keep that on board. Different things like that just to try to make both the systemic and the local symptoms a little bit more tolerable.

Jennifer Gomez:

Yes. Do you have a protocol that you use for, that you put everybody on for urinary urgency frequency or do you wait for them to develop symptoms before you treat?

Meredith Donahue:

I don't, because, like we said, no two patients are the same and I'm going to treat a 65-year-old man with 100-gram prostate a lot differently than I'm going to treat a 75-year-old woman who's been through menopause. So of all of our new patients starting therapy, I assess their LUTs before starting and then try to get them on appropriate therapy before they come in and then we can keep an eye on it throughout.

Jennifer Gomez:

Yes. Do you have a favorite anticholinergic or medicine that you use for bladder spasms?

Meredith Donahue:

I should first say not oxybutynin.

Jennifer Gomez:

Yes, me neither.

Meredith Donahue:

No one should be using oxybutynin anymore, just with the recent data on increased risk of dementia and all that. If they have–especially the women–if they're having every day, just their baseline is frequency, urgency incontinence, then I'll try to get them on a Gemtesa or Myrbetriq at least a few weeks before if I can. If it's more they just have those frequency, urgency, difficulty holding their treatment, then trospium I like. It works quickly, usually well-tolerated.

Jennifer Gomez:

Yes, I like solifenacin. I feel like it's pretty well tolerated. It's my go-to typically. I like that it's only once a day too.

Meredith Donahue:

Yes, for sure. And then, of course, Pyridium as needed for burning.

Jennifer Gomez:

Yes. Ibuprofen for the bladder.

Meredith Donahue:

Yes. Yes, that's a good way to say it. And so with that, what else can APPs do? That's before treatment even starts, but what about during treatment? I know I'm doing right now almost 70 patients a week intravesical therapies, and so that can bring a lot of day of decision-making. So nitrate-positive urine is one thing. How do your institutions manage that?

I know for us, again, I'm doing all of these treatments and so I'm the provider there and can make these decisions. And I really try not to, just because they're positive doesn't mean don't get treatment. If I see somebody has a positive urine, then I want to know if they're having any symptoms, and then I look at what they're getting. If they're getting BCG, I'm going to have a much lower threshold to say, "We probably shouldn't give treatment," vs if they're getting intravesical chemo, I might be a little more willing to give treatment in the setting of an infection. But I'm curious how you're…

Jennifer Gomez:

Yes, so it works just a little differently at my institution because I'm not actually giving the treatments. So we have a BCG clinic that's run in our office while I'm doing a separate clinic. And so frequently the nurses, if there's any question, will come and if we need to make a same-day decision or if someone's not tolerating treatment well, I'll add them on. We'll see what we can do about their urinary symptoms.

Meredith Donahue:

And talk about it.

Jennifer Gomez:

And talk about it. Because I'm not the one giving the treatment, we do have protocols in place. So if they're positive for leuks and nitrates, typically their treatment, and they're symptomatic of a UTI, their treatment is going to be delayed, and that's just written into our protocol.

Meredith Donahue:

Yes. And I think that's pretty standard. And also checking in, maybe they took a Pyridium right before they came and that might be why their urine is positive.

Jennifer Gomez:

Yes.

Meredith Donahue:

So just, I think, having that protocol of nitrate positive, symptomatic.

Jennifer Gomez:

Symptomatic, yes.

Meredith Donahue:

For sure. Symptomatic is the big one.

Jennifer Gomez:

Yes. If they're symptomatic of a UTI, you've got to confirm before you give BCG.

Meredith Donahue:

Yes. And I think also I find a great part about having a provider running our BCG clinic or bladder installation clinic is my very good understanding of all of the treatment options. I find a lot of times patients are told they have, or we all know this, patients are told they have cancer, they're told they have recurrence, and then everything after that is in one ear and out the other. So then when they come to get treatment, they've had time to sit on it and think about it, and I can really go through why are we doing this treatment? What does it look like? And all of that. But they may not have-

Jennifer Gomez:

Yes. It's also, it's a touchpoint. Having a provider at least involved in the intravesical therapy pathway, especially an APP, is super important because they see their surgeon and they order their induction course, and then if they're symptomatic, they're having issues for those patients to contact the office and get in touch with their provider sometimes can be really challenging. And so having that touchpoint and having those people there that can snap into action and help manage the symptoms is super important.

Meredith Donahue:

Yes, that's a really good point. Just more touchpoints with them because trying to call or send messages can get lost a lot of times.

Jennifer Gomez:

Yes. Or they think it's normal and they just sit on it.

Meredith Donahue:

Yes, yes. That's a good point. I was going to say that too. There's been plenty of times where I ask a patient, "How are you doing?" And, "Oh, well, I had fever of 104." I'm like, "Okay, we probably should have known about that."

Jennifer Gomez:

And you're like, "Oh, no."

Meredith Donahue:

Yes. Should have known about that one. But perfect. And then after treatment, we kind of have touched on all of this, but just assessing where the patient has a hard time, whether that's a hard time holding the treatment. Is it they're having local bladder side effects for the days or weeks after? Are they having systemic side effects after? And all of the different ways that we can manage those side effects. And like you said, making sure patients know that you can tell us what side effects are and you don't have to suffer through it and that X, Y, and Z might be normal. I just need to know about it.

Jennifer Gomez:

Yes. It's also super, I think, worth mentioning that we can't forget about our colleagues in physical therapy who can help with pelvic floor physical therapy or the sexual side effects that come with BCG. So for men, ED. For women, all sorts of pelvic pain, and making sure that we're asking and addressing those things as well.

Zuzana Lacca:

I was going to say real quick, it's really helpful that, especially when you provide your rationale in your notes. I always read you guys' notes, not you personally, but my colleagues. And it's always helpful because when I'm sitting there with a patient and we're talking about their symptoms, so then I can differentiate what could it be, what I could be looking at, when should I reach out to you?

And the same thing as I mentioned with the transvaginal estrogen, we know now that we can use it even in breast cancer in a lot of the settings, right? So I still have providers reaching out to me even after it is mentioned in my note, is it okay to give? And I feel like that having that some way of how we can communicate where we can maybe cut down on some of that unnecessary communication, but of course it doesn't mean that we should discourage it. We are here for each other sharing our expertise.

Meredith Donahue:

Yes, and that's a good point. If I see a woman has a history of breast cancer, then I'll send an FYI to their breast oncology team and just say, "Hey, making sure we're all on the same page." But like you said, there is very good data to show there's very little risk there.

And Jenny, you kind of took the words out of my mouth with all of the multidisciplinary approach that we can use in this patient population. Of course, medical oncology, but you mentioned pelvic floor physical therapy. They can truly work wonders sometimes. Even psychiatry, I know we have a psych onc group, so psychiatrists who specialize in patients or people with cancer, and also the sexual medicine and all of that, that plays into being successful with intravesical therapy.

All right. I think before we end, we've been talking about all these side effects that can come with these therapies, but I do just want to run through the treatment options for high-risk NMIBC. We've talked a lot about BCG, but we are at a really exciting and lucky place in bladder cancer care right now, where we do have a lot of treatment options for these patients.

So of course, BCG, we've got intravesical chemo, that might be gemcitabine monotherapy or gemcitabine plus docetaxel. We've got nadofaragene firadenovec. We have nogapendekin alfa inbakicept, which is given with BCG. Really, the one that's given very differently than all of these other options is the TAR-200, which is a gemcitabine intravesical device, which is also commonly known as the pretzel. And then kind of the most recent, we've got BCG plus durvalumab, which is BCG plus IO therapy. Pembrolizumab, that's been around for a while. And then also one of our new kids on the block is cretostimogene. So lots of options, lots to consider to get these patients through this disease state.

But this brings us to the end of this discussion. Please see our two other segments for further discussion on non-muscle invasive bladder cancer at JADPRO.com.