Bladder Cancer in Women: Improving Diagnosis and Treatment - Jean Hoffman-Censits

April 15, 2019

Jean Hoffman-Censits joins Alicia Morgans and shares details on the Johns Hopkins women’s bladder cancer program.  This program is created in recognition of the pathway that women frequently take in the diagnosis of their bladder cancer. We often see a delay in the diagnostic process of bladder cancer in women compared to men.  This delay in diagnosis leads to what is thought to be stage migration.  The discussion is centered on educating clinicians and patients about the need to consider the possibility of bladder cancer in women who present with hematuria and to refer these women to a urologist for timely diagnosis and treatment.   

Biographies:

Jean Hoffman-Censits, MD. is a genitourinary medical oncologist at the Greenberg Bladder Cancer Institute and the Co-Director, Women’s Bladder Cancer Program at Sidney Kimmel Cancer Center at Johns Hopkins. Her clinical and research interest is in the treatment and development of novel therapies for cancers of the bladder, ureter and renal pelvis. She attended Jefferson Medical College, Medical School and spent her residency and fellowship at Thomas Jefferson University Hospital and the Fox Chase Cancer Center in Philadelphia, PA, respectively. Dr. Hoffman-Censits is board-certified to practice Internal Medicine and Medical Oncology and administers chemotherapy and cystoscopy to patients with a range of urogenital cancers. Her extensive publications cover a range of genitourinary cancer topics, including “Identification of Distinct Basal and Luminal Subtypes of Muscle-Invasive Bladder Cancer with Different Sensitivities to Frontline Chemotherapy“.

Alicia Morgans, MD, MPH Associate Professor of Medicine in the Division of Hematology/Oncology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois.
 

Read the Full Video Transcript

Alicia Morgans: Hi. I am delighted to have here with me today Dr. Jeannie Hoffman-Censits who is an Assistant Professor of Medical Oncology and Urology at the Johns Hopkins School of Medicine. She is the Co-Director there of the women's bladder cancer program and the Johns Hopkins Greenberg Bladder Cancer Institute. Lovely to have you here today. 

Jeannie Hoffman: Thank you so much for having me, Alicia. 

Alicia Morgans: I am so excited to have you because you have been able to start a women's bladder cancer program. 

Jeannie Hoffman: Yes. 

Alicia Morgans: This is unique I think across the country, potentially in the world, I don't know, but I was really thrilled to hear about your endeavor to get this started to really serve a population of people who sometimes I think is overlooked when we think about bladder cancer. I'd love to hear about how things are going. 

Jeannie Hoffman: Sure. Sure. Well, you're absolutely right. I think we both know we've seen a lot of women with bladder cancer over the years. I think one of the things that we notice when we see women with bladder cancer is that their story, that history and physical that we get, their story is very different than men. 

Alicia Morgans: Yes. 

Jeannie Hoffman: They have the same symptoms when they present with bladder cancer. What gets them to their doctor's attention is blood in their urine or irritative voiding symptoms, but the path that women take is different than men. Oftentimes, women see their primary care physician or empirically treated with antibiotics sometimes over and over and over again going on for weeks, months, sometimes even years, right? 

Alicia Morgans: Yeah. 

Jeannie Hoffman: Where men, most men have either had interaction with a urologist before or often directly referred to a urologist. What happens during that period of time is there's a delay in the diagnostic process for women. And that delay we think is contributing to one of the things that we know is a big problem when it comes to bladder cancer is that if you're a woman and you have bladder cancer, you're at a higher risk of dying than if you're a man with bladder cancer. We think that that delay and the time of diagnosis can cause something called stage migration where tumors can grow unchecked before they're detected. We think that this is a really important problem. 

So important that we wanted to dedicate a center to start recognizing this problem, which we really recognized for a while, but trying to make a change into how we manage it. 

Alicia Morgans: What do you have in this program that really differentiates it from others or is really kind of raising the bar in your program? 

Jeannie Hoffman: Yeah. That's a great question. I think one of the things is just the recognition that this is a problem. It's a problem that we have studied. It's a problem that's been reported in the literature, but it's never been a problem that we've said, "We're now going to do something about this." I think really the time is now to think about how we can affect change. One of the ways to affect change is awareness. I think the awareness of having a medical home for women that have bladder cancer is important. 

That's one thing. I think also raising awareness not only among patients to maybe tell their physician, "Look, I've had three or four visits to gynecology or to GYN for blood in my urine," and it's important that primary care physicians and other physicians refer women to a urologist when they complain about a urologic problem. I think that's one of the big things that we're doing. The other thing is again in developing a medical home for women that have bladder cancer. When women are often referred to urologists because they have these symptoms and are ultimately diagnosed with bladder cancer, they're often being seen in an environment that might be somewhat foreign. 

Most of the patients in waiting rooms in urologist office are men and less than 10% of urologists are women. They're going to places they've never been before, sitting around with people that don't look like them and seeing a doctor that doesn't have their same life experience. It's something that I think just kind of recognizing that experience that women are having and at the same time knowing that they're not getting the same level of care and at the same time we're just understanding that at the end of the day their prognosis is worse. I think we need to just take more time and dedicate that to women. We're developing a space that we think is more welcoming. 

This medical home, although it's at Johns Hopkins, is at a campus in Washington, D.C. We have a campus called the Sibley Hospital Medical Campus. It's a hospital that's been there for a long period of time really focusing on women's health. Sibley has a women's health program, and so we're looking forward to joining forces with them to really deliver multidisciplinary care to women that are coming to meet with us for their bladder cancer. 

Alicia Morgans: I think that's fantastic because like you said, probably one of the biggest impacts you can have among other things, like the multidisciplinary care and feeling comfortable and welcome, would be the awareness that's raised by having a program specifically dedicated to women because primary care doctors can think about this and maybe it comes to mind a little more quickly before the third round of antibiotics because women do get urinary symptoms sometimes. They do get urinary tract infections. There is a diagnostic challenge there. But if we aren't thinking about these things or if primary care doctors aren't thinking about bladder cancer as being on the differential, it's really hard to diagnose it. 

I commend that you put together the program, you and the team are putting together the program, to not only care for patients but to raise awareness of the issue. 

Jeannie Hoffman: Right. You're absolutely right. You and I both know that on the differential diagnosis of hematuria in women, bladder cancer is very low on the list. When you look at all the 80,000 patients every year that are diagnosed with bladder cancer, the majority are men. Three-quarters are men. It's the fourth most common cancer in men. It's not as common in women, and so PCPs might not be thinking about it. The other physicians that care for women might not be thinking about it. I think most importantly, patients who are their own best advocates aren't always thinking about it. 

Most of the time when people are diagnosed with bladder cancer, it's the first time they've ever said about the disease, which is really amazing when you think about ultimately how common it is. We do think that those factors are important. Some of the other things that we know about the difference in care between men and women with bladder cancer is once women get to the urologist office and get beyond that waiting room, they may also be seeing a doctor that again doesn't potentially have as much experience in women or having as much experience doing the transurethral resections in women. 

I'm not a urologist, but a much more sometimes difficult procedure because women's bladders are thinner than men's and at higher risk of perforation during biopsies. That puts women at risk for not having a complete biopsy, which we know could lead to under staging, undertreatment and again contributing to that inferior outcome that we see. 

Alicia Morgans: Absolutely. Well, I commend you and the team for putting this together. I would love to hear your closing message to the viewers about this so that we can make sure we close on a take home point that gets people into clinics, whether they're at your center, which is really incredible and exciting, or whether it's locally wherever they're watching to kind of take the next step. If they've got blood in their urine, they do need to think about getting diagnosed. What is your closing thought? 

Jeannie Hoffman: Sure. Well, I think that like all things that are done best in medicine, they're done collaboratively. One of the things that we're really excited about is having the first we think ever academic meeting focusing on women with bladder cancer. We're having a patient forum. We're talking about surgical issues, response to treatment, all different kinds of things. We're bringing in experts from around the country who think about this. 

I'm hoping that as we continue to build a network of people who think about this, of course, we know that everyone can't come to Johns Hopkins, but to think about a network of physicians who really think about this think of it as an important factor in bladder cancer that we can continue to move the field forward. Maybe in five years from now, we can sit down and talk about how patients who are men and women are doing just as well with bladder cancer. 

Alicia Morgans: That's phenomenal. As your network expands, make sure you include Northwestern in your network. We would love to be a part of whatever you're doing. Can you just tell us when is that summit going to be or your meeting? 

Jeannie Hoffman: It's a joint summit between Johns Hopkins and the AUA, and it's going to be March 21st and 22nd at the AUA headquarters. 

Alicia Morgans: Okay. Great. Well, hopefully, people can join you there. If they can't, maybe we'll talk again and we could talk about what a success it was and what are some of the key points of that meeting were. We can put it on UroToday at some other point. Thank you so much, Jeannie, for your time, and thank you, everybody, for listening. 

Jeannie Hoffman: Thank you for having me.
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