As a urologic oncologist specializing in bladder cancer, I treat patients across the disease trajectory, from non-invasive to advanced disease. Regardless of where they fall on this spectrum, most new patients arrive to see me without having been told even the most basic facts about their disease – its causes, risk factors, progression, treatment, or prognosis. This leaves them feeling confused, isolated, and disempowered.
Bladder cancer is complicated, which only heightens the need for physicians to go the extra mile when educating our patients. It is important to devote time to this aspect using the clearest terms possible, together with good visuals. I explain that treatment consists of a series of personalized steps that we will take together through each stage of their disease. Even for patients with earlier-stage bladder cancer, it is important to explain that the future could present a more serious event, such as radical cystectomy. This allows patients to see the path forward more clearly. At the end of the appointment, the patient and I should be on the same page regarding not only their current needs but also their overall landscape of outcomes.
This time investment pays off. Almost invariably, patients express a sense of enlightenment and a new perception of themselves as active partners in their care. For example, learning that smoking is a leading risk factor for the onset, progression, and recurrence of bladder cancer often spurs patients to quit, while understanding the importance of healthy nutrition and exercise during immunotherapy helps them prioritize these behaviors. Likewise, patients who grasp the fundamentals of bladder cancer progression and treatment are more likely to report and accurately describe their symptoms and any side effects.
Historically, bladder cancer has been among the most difficult genitourinary malignancies to manage while also conserving patients’ quality of life. During my formative years as a resident and fellow, this challenge inspired me to devote my career to it, and I am deeply indebted to many talented mentors who helped me along the way. My goal now is to improve the lives of patients with bladder cancer not only case by case, or surgery by surgery, but also by helping train a new generation of urologic oncologists who can take their skills with them wherever they go. Many fellows my colleagues and I have helped teach now lead programs at their own institutions. I also often travel to other cities and countries and sit down with the local teams of urologists, oncologists, and advanced practice providers who are in the process of setting up local centers of excellence. Our hope is to improve the lives of patients with bladder cancer around the world.
The past five years have seen an explosion of approvals of molecular and targeted therapies for the treatment of bladder cancer, with parallel strides in care pathways, diagnostics, and surgical technologies.2-9 One major advance in surgery is the adoption of enhanced recovery pathways; as a result, patients are returning home sooner, with better outcomes. It is easy to zoom in on this exciting present and lose sight of both past and future, but to do so risks a return to stasis. We need to remember that current progress reflects ceaseless work and sacrifice by scores of investigators, clinicians, and patients. Our focus now should be to sustain that momentum, to channel all the excitement about these recent advances into renewed efforts to educate clinicians and innovate new diagnostics, therapies, and strategies for the managing bladder cancer. Doing so will help all our patients realize the best possible future.
Written by: Ashish Kamat, MD, MBBS, Professor of Urology and Wayne B. Duddleston Professor of Cancer Research at MD Anderson Cancer Center in Houston, Texas. Dr. Kamat serves as; President of International Bladder Cancer Group, Co-President of International Bladder Cancer Network, and Associate Cancer Center Director. Dr. Kamat served as the Program Director, of the MD Anderson Urologic Oncology Fellowship from 2005-2016.
1. Cancer Stat Facts: Bladder Cancer. Accessed May 9, 2019.
2. Bellmunt J, de Wit R, Vaughn DJ, et al. Pembrolizumab as second-line therapy for advanced urothelial carcinoma. N Engl J Med 2017 Mar;376(11):1015-1026.
3. Patel MR, Ellerton J, Infante JR, et al. Avelumab in metastatic urothelial carcinoma after platinum failure (JAVELIN Solid Tumor): pooled results from two expansion cohorts of an open-label, phase 1 trial. Lancet Oncol 2018 Jan;19(1):51-64.
4. Powles T, O'Donnell PH, Massard C, et al. Efficacy and safety of durvalumab in locally advanced or metastatic urothelial carcinoma: Updated results from a phase 1/2 open-label study. JAMA Oncol 2017;3(9):e172411.
5. Rosenberg JE, Hoffman-Censits J, Powles T, et al. Atezolizumab in patients with locally advanced and metastatic urothelial carcinoma who have progressed following treatment with platinum-based chemotherapy: a single-arm, multicentre, phase 2 trial. Lancet 2016 May 7;387(10031):1909-1920.
6. Sharma P, Retz M, Siefker-Radtke A, et al. Nivolumab in metastatic urothelial carcinoma after platinum therapy (CheckMate 275): a multicentre, single-arm, phase 2 trial. T Lancet Oncol 2017 Mar;18(3):312-322.
7. Rosenberg JE, Sridhar SS, Zhang J, et al. Updated results from the enfortumab vedotin phase 1 (EV-101) study in patients with metastatic urothelial cancer (mUC). J Clin Oncol 2018 May;36(15_suppl):4504-4504.
8. Siefker-Radtke AO, Necchi A, Park SH, et al. First results from the primary analysis population of the phase 2 study of erdafitinib (ERDA; JNJ-42756493) in patients (pts) with metastatic or unresectable urothelial carcinoma (mUC) and FGFR alterations (FGFRalt). J Clin Oncol 2018 May;36(15_suppl):4503-4503.
9. U.S. Food and Drug Administration. FDA approves first targeted therapy for metastatic bladder cancer. https://www.fda.gov/news-events/press-announcements/fda-approves-first-targeted-therapy-metastatic-bladder-cancer Accessed May 9, 2019.
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Watch: ERAS in Bladder Cancer - A Conversation with Ashish Kamat and Sia Daneshmand