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Leslie Ballas: Hi, I'm Leslie Ballas. I'm a radiation oncologist at Cedars-Sinai in Los Angeles. I am fortunate to be joined by Dr. Elizabeth Guancial. She is an oncologist at the Florida Cancer Specialists and Research Institute and is a specialist in genitourinary malignancies. Welcome, Elizabeth.

Elizabeth Guancial: Thanks so much, Leslie, for the invitation.

Leslie Ballas: Today, we are going to talk a little bit about the difference between treating women and treating men with bladder cancer. And so why don't you start by just telling me what your experience has been in treating women versus men and maybe even remind our viewers about the discrepancy in presentation in terms of just raw numbers between women and men with bladder cancer.

Elizabeth Guancial: Yeah, great questions, Leslie. So I'm a little unique. I've practiced both in academics and I've now been in community practice for the last six years. So I've seen both environments in terms of how women present. I think across the board, though, women tend to present at a later stage, and there's usually more of a workup leading up to the point when they come over to me as a medical oncologist.

What I mean by that is, for a man to have blood in his urine, that's abnormal. And usually primary care physicians will check for prostatitis, check for UTI, and then get them right over to a urologist.

With women, it takes longer. They may go through multiple courses of antibiotics thinking, “Oh, it's a urinary tract infection that's hard to treat. Maybe it's related to vaginal bleeding—postmenopausal bleeding.” Sometimes they'll even see a gynecologist before they eventually get to a urologist. And this has been documented in the literature also, that it takes longer for women to actually make it to a urologist.

Once they do, usually the workup from there is pretty streamlined. But I think that's the key step for women to actually get in with the urologist, because they're typically the physicians that would refer them over to me as a medical oncologist.

Leslie Ballas: And do you feel that there's something that we should either tell our primary care providers or our patients so that there isn't that delay in workup? What would be a good tip?

Elizabeth Guancial: Yeah, I think education for primary care physicians is really key to all of this, as the gatekeeper for these types of referrals. The initial workup is obviously important. You want to make sure it's not a simple urinary tract infection. But when things aren't clearing up quickly, getting that ultrasound, getting them over to a urologist as quickly as possible, I think, is really important.

As far as patient education, different forums—specifically BCAN (Bladder Cancer Advocacy Network)—I think throughout their literature, whether it's website, podcast, printed publications, it's all in there: blood in your urine is not normal, seek out care very quickly. And we see a difference, I think, when patients do get to us earlier on, once the diagnosis has been made. Very often they have an earlier stage of disease, and so it opens up a lot more treatment options for them. And it's also associated with better outcomes. Any delay in that initial workup, I definitely think contributes to the disparity that we see in terms of gender outcome.

Leslie Ballas: Thank you. I guess, to that point, when women are presented with treatment options up front, do you think that they evaluate their treatment choices differently? Do they opt for cystectomy versus bladder preservation more frequently? Is it... and then why? I mean, is it based on sexual quality of health, views on survivorship?

Elizabeth Guancial: Yeah, I think women, in general, tend to be more thoughtful in terms of considering all of their options. I can think in recent months having male patients come in—“I'm not doing that, just end of story.” I don't know—I’m not a researcher when it comes to the whole thought process behind it, but, anecdotally, I can say the number of patients I have who, up front, say, “I'm not doing that”—it tends to be more men.

Women, I think, maybe do a better job of hearing out what their options are. And they seem to be more open to, all right, thinking about, what would surgery look like? Radiation, what would that look like?

My preference for someone who has muscle invasive disease, who has all of these treatment options, is I want to get them to the right specialist. Let’s have you meet a urologic oncologist. Let’s have you meet a radiation oncologist and think about what makes the most sense for you.

Being in Florida, where I am, I treat a lot of older patients. And so the question about sexual function seems to be less of a factor as women weigh their options. I do think that the cosmetic thoughts about, what is it going to look like having a urostomy?—that definitely weighs heavily on both genders. Sexual function seems to be less, but certainly pain. That's a major factor for a lot of people.

The barrier I often find to radiation is the time required. Again, thinking about an older patient population, the idea of having to get back and forth from treatment for five or six weeks—for some people, that can be really overwhelming.

On the other hand, the idea of a really complicated surgery and being hospitalized for a week or longer—that can sometimes dissuade people. So as a medical oncologist, I like to really dig into that, circle back after people have had their second opinions in terms of these options, and think about what would make the most sense for them as far as treatment.

I think for people with advanced disease, oftentimes they’re super symptomatic. And that’s where—the more symptomatic a patient is, I find, the more trusting they tend to be in terms of just moving on with it. And this is across gender: “I’ve got advanced disease, I don’t feel well, what do you think is the best treatment option?”

One of the focuses for our practice as a whole is getting people in quicker. And even though we may not have all the information that we need, at least starting from the beginning to establish that relationship, even if it’s still going to be a couple of weeks before we can make our decision about systemic therapy, what can we do right now to address your pain? What can we do to address the weight loss, or the nausea, or the insomnia, or whatever it might be?

For advanced disease, I don’t find that there’s a lot of gender differences. People are symptomatic and they just want to move forward.

We also obviously have to cover end-of-life discussion and expectations. And there as well, I don’t see as much of a gender difference, though sometimes I will hear from women, “I don’t want to be a burden on my family. I know—I’ve always had the primary caretaker role, things have been switched, I can tell how much time and effort my family is spending shuttling me to appointments, picking up my prescriptions, helping with the household activities.” And I will say more frequently I hear that from women, which is always heartbreaking, especially when you can tell the family’s invested from the beginning and they just want as much time and quality for that loved one as possible.

Leslie Ballas: Yeah, I hear that too. When we are giving palliative radiotherapy for these patients, absolutely.

Elizabeth Guancial: Yeah.

Leslie Ballas: And just because I’m a radiation oncologist who believes so strongly in bladder preservation, I’m just going to tell you that you can do it in four weeks instead of five to six. And so I want that to be—excuse my bias there, I have to say it. And even for some of the most elderly patients, you can do it once a week for six weeks. That’s a regimen that’s been used in the UK—

Elizabeth Guancial: Wow.

Leslie Ballas: —and we’ll use sometimes for our most frail patients, who sometimes have the hardest time getting back and forth. So there are options.

Elizabeth Guancial: That’s amazing. I did not know about the once-weekly. We do tend to offer a fair amount of chemoradiation. Not necessarily it’s the Olympic athlete who’s the ideal candidate, but it’s more you have disease, you’re not a great candidate for cystectomy for a variety of reasons, and in those situations—when we’re not necessarily going for 10-year outcomes, we’re looking for more 18 to 24 months—that’s where we will sometimes shorten the total course. But I’ve never heard of the weekly regimen. So I’ll have to circle back to my rad onc colleagues about that. That’s amazing. Kudos to the UK.

Leslie Ballas: Yeah, they’ve done amazing work in bladder cancer.

Elizabeth Guancial: Yeah.

Leslie Ballas: So back to our discussion about how you perceive—or how female and male patients perceive—their choices and make decisions, do you think that patients respond to you differently as a female provider?

Elizabeth Guancial: I do. Part of it, I would say, is I may be the first female that they’ve had in their treatment workup once they’ve been diagnosed with bladder cancer. Most—actually all—of the urologists in my area are men, and they do an amazing job. But patients are just used to maybe not delving in as much to what’s life like at home, what are your priorities, that type of thing.

When I see a new patient, I have an hour appointment, and it usually takes a full hour. I mean, there’s a lot to go through, and these patients tend to be really sick. So we spend a lot of time with them up front.

My subsequent visits are not an hour, though patients sometimes think they are. So I think we do end up, whether it’s because of that scheduling or as a gender thing, I think patients expect to share more detail and to get more time in return. And I know my male colleagues don’t necessarily have that same expectation.

I do think, in the long run, I have more work after the visit, but I do think that we come up with a solid plan that hits on all of their priorities. And I do feel that our patients feel more comfortable with what that treatment plan is, because they feel like, all right, I’ve taken the time to really vet all of this and come to this shared decision-making.

Again, I don’t know how supported that is in the literature, but I do think I’ve seen before that patients expect—and they do actually spend more time—with their female physicians. And, in some series, they have better outcomes as well, which, I think, would be directly related to that.

Sometimes I find I have to do boundary setting with my patients—and this, not necessarily female patients, but across the board—because we’re spending so much time with them, we have to explicitly say, “I’m not your primary care doctor. I’m not checking your lipids or your vitamin D. I’m not titrating your levothyroxine, unless you’re on Keytruda.”

And so sometimes there’s a little bit of a, “Oh,” a surprise. But I think, as a female physician, I try to be as objective about things and not make it a big emotional scene. As your doctor, this is what my job is.

The one gender difference I have seen with patients is the expectation that they will always see the physician. So, again, at the first visit, I lay out, “Here’s how my team works. I’m the physician. I’m the one who’s ultimately responsible for your care and making decisions with you. But I have a team, including nurse practitioners, and we will be alternating visits.”

Most women seem to understand that, and the number of times we have to have the behavior talk is minimal. The majority of the time when I have patients who really struggle with that, it tends to be men—“I don’t…”—and oftentimes men who don’t have women involved in their care. If it’s a male who’s married or has a daughter involved, that seems to go over pretty easily. But sometimes, for a male patient who comes alone, there can be this pushback early on about, “Well, I need to see the physician at every visit.” And I don’t know if my male colleagues get that same behavioral issue. It can be a challenge.

Leslie Ballas: That’s interesting. I hadn’t thought about that angle. That’s a really interesting component. You mentioned that the urologists in your area are all men. Commonly, in genitourinary malignancies—I think historically, because urology and urologic oncology has been more heavily populated by men—there haven’t been as many women in this area. Have you found that that’s something that is either a plus for you or something that you don’t like? Do you find that there’s more of a community amongst the women who are doing GU? What has been your experience on a professional level?

Elizabeth Guancial: I think my male colleagues are terrific. I think they’re excellent urologists, and I really appreciate the direct communication we have with our patients. I think sometimes the patients who are women will ask me more urologic questions than I’m necessarily capable of answering just because I’m not a surgeon. And it may just be they feel more comfortable with a female physician asking them about sexual function after cystectomy. What exactly is this surgery going to consist of? So there can be that difference.

But I think, as far as gender goes with the actual urologic oncology community, I’ve felt very comfortable. And I think sometimes for male patients there can be a little bit—not as much actually as 10 years ago—I think patients now seem pretty comfortable. “If my urologist thinks you’re good, I’m happy to see you.” It doesn’t really come up as often, I think, as I would have initially thought it would.

I think there is a terrific community among females who focus on genitourinary oncology, whether it’s radiation oncologists or medical oncologists. I think ASCO has done a really great job of trying to encourage these minority groups—because that’s what we are—of having opportunities for networking and meeting each other at different professional meetings. And that’s really helped.

At the past ASCO meeting—I know where you were, Leslie, a couple of weeks ago—they had a couple different forums, whether it was a cocktail hour or a luncheon. And it is a nice way to try to get everyone together to talk about topics that may not warrant a plenary session, but there are issues that we deal with on a regular basis: how to delegate work, how to approach patients who may have some gender bias when it comes to their medical teams, how to create some type of a balance that works for you between time at work and time at home. So I think that’s something I’ve seen more of within the last five years, I would say, as opposed to before that. And I think it’s a welcome change for the field.

Leslie Ballas: Well, I can’t thank you enough for taking the time to talk with us today about your experiences, both professionally and with your patients. Thank you, Dr. Guancial.

Elizabeth Guancial: My pleasure, Dr. Ballas. Anytime.