Improving the Bladder Cancer Survivorship for Women

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology.

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Sheppard, a medical oncologist, Director of International Programs for the Cancer Institute, and Co-Director of the Sarcoma Program at Cleveland Clinic. Today, I'm happy to be joined by Dr. Laura Bukavina, a Urologic Oncologist here at Cleveland Clinic. She's here today to discuss how to improve bladder cancer survivorship experiences for women. So, welcome.

Laura Bukavina, MD, MPH: Thank you. Thank you for having me.

Dale Shepard, MD, PhD: Absolutely. So, give us a little bit of an idea of what you do here at Cleveland Clinic.

Laura Bukavina, MD, MPH: So, I am a urologic oncologist, which, to people who don't know, I'm a urologist, but I specialize in cancer, particularly in bladder and kidney cancer. I'm also the translational research lead for genitourinary oncology.

Dale Shepard, MD, PhD: Excellent. So, we're going to talk about bladder cancer survivorship. And just in general, just so we know the scope of things, what's the incidence of bladder cancer? How many people are we talking about that might get bladder cancer?

Laura Bukavina, MD, MPH: So, it's the sixth most common if you look overall for both sexes, but it's more common in men than it is in women. So, in men, it's about, we're talking about 100,000 cases in terms of the regional US, but in women, it's a three to one ratio, so we're talking a lot less women. The problem is that we know that women generally tend to get more aggressive disease, so while there's a lot of non-muscle invasive, so less aggressive type of cancer in men, women generally present to us at a far later stage down the line.

Dale Shepard, MD, PhD: And when people get these muscle invasive cancers, what kind of treatment do they typically need?

Laura Bukavina, MD, MPH: There's been a shift. So, historically speaking over the last 50 years, it's always been chemotherapy followed by consolidative surgery, so removal of your bladder in women, removal of ovaries. I say everything out. So, you take the uterus, you take the ovaries, you take the tubes out, but that's have shifted. We're now focusing more on not only preservation of organs, we're also focusing and shifting our goal to potentially organ preservation in terms of the whole bladder preservation. So, there's a spectrum of saving some organs, preservation of nerves, or potentially doing what's called complete organ preservation or bladder preservation programs.

Dale Shepard, MD, PhD: We're mostly going to talk about survivorship, but it's important to know what's involved from a treatment standpoint because that leads to some of the issues.

Laura Bukavina, MD, MPH: Yeah.

Dale Shepard, MD, PhD: Tell us a little bit more about the organ preservation part, because you're right, the traditional teaching is that if it's muscle invasive, the bladder has to go.

Laura Bukavina, MD, MPH: Yeah, and that's been debunked multiple times. The reason why we used to take them out all the time is thinking that, A, women are going to develop ovarian cancer down the line. If we're there, why not just take the ovaries out? B, the thought of cancer spreading to nearby organs, and that still might be the fact to uterus or vagina in some cases, but very little evidence to show that many of our patients of any spread to the ovaries. And then three, potential of this surgical thinking that it's much easier to do everything in block than it is to separate your uterus, your vagina from the bladder. So, you're limiting the complications by taking everything together.

And those reasons really have been debunked over the last decade. We know that women after generally age of 60 and 70 are not more likely to get ovarian cancer if they've had bladder cancer. It just doesn't work like that, even patients with germline mutations. The second thing, we've shown over and over now with whether it's open or robotic surgery, that it's very feasible to save, and patients don't have more complications if you're saving organs. And three, the risk of bladder cancer spreading to organs, such as your ovaries or your uterus, is very low as long as you do a very thorough evaluation before you do the surgery.

Dale Shepard, MD, PhD: And you've talked about complications, but that's complications directly related to the procedure. Tell us a little bit about when you think about survivorship, what are some of the complications after treatment?

Laura Bukavina, MD, MPH: So, nerve preservation and nerve damage. So, a lot of the female nerves that supply vaginal lubrication, orgasm, climax, run along the urethra and along the anterior vagina, and that's our dissection field. So, if we're taking everything out and not sparing the organs, the chances that a female is going to have a normal sexual function afterward, it's low. It's less than 10%.

The other thing is we're talking about vaginal actual removing part of the vagina. So, essentially half of the vagina is gone if you're doing the standard approach, which is called anterior exoneration. So, you're working with something that was a functional vagina to now potentially only a two, three to centimeter vagina, and you're really not going to be able to be sexually active.

And then the third thing is, even if you spare the vagina, a lot of those women experience side effects such as prolapse and teraseals, where essentially your insides come out to your outsides. And that's not attractive in any sense.

Dale Shepard, MD, PhD: So, historically, how have we addressed these functional things, sexual function in a survivorship setting?

Laura Bukavina, MD, MPH: We're getting better at it. So, we learned from our prostate days that nerve preservation makes a huge difference in outcomes, so taking what we learned in robotic surgery on nerve preservation and prostate, we're now applying very similar concepts in bladder cancer. So, preservation of nerves, preservation of vagina, preservation of the clitoral plexus. We're applying the same lessons.

We also are learning new techniques. We now know that a lot of the patients, when you see them initially and they might a stage three tumor or a stage four tumor, as our therapies are getting better, and a lot of our patients do get neoadjuvant therapy before the surgery, is tumors are shrinking. So, while you might not be able to spare all the nerves and organs right away when you see the patient, understanding that there's probably a chance they get down-staged after chemotherapy to where the conversation can happen down the line. So, using everything we learned from colorectal literature, from our prostate literature and applying it to our bladder cancer patients.

Dale Shepard, MD, PhD: So, it sounds like multidisciplinary care is really important.

Laura Bukavina, MD, MPH: Absolutely.

Dale Shepard, MD, PhD: How do we ensure that here at places like Cleveland Clinic?

Laura Bukavina, MD, MPH: Tumor Board is essential, so having great relationship with your medical oncology, radiation oncology colleagues. So, Tumor Board presentation, making sure that the patient's plugged in. And even if they're not chemotherapy eligible, they might be eligible for other trials for down-staging of their disease. So, having existing and well-established relationships with radiation and oncology and medical oncology.

Dale Shepard, MD, PhD: Does that get even better? I just remember back when I had finished fellowship and seen bladder cancers, frequently I would see a patient that just had their bladder resected and there wasn't ever a consideration of neoadjuvant therapy. And so there's a vacuum between disciplines. Has that gotten better?

Laura Bukavina, MD, MPH: I think so. Especially here, I think we're very good. We're probably somewhere between 50% to 60% of our patients get neoadjuvant chemo. The other percent that don't is because they're usually not eligible because of their cancer or their kidney function. So, yes, I think we know it works. It works well.

We're also incorporating a lot of newer technology. So, we're now talking about circulating tumor DNA regularly with our patients. We're talking about MRI specifically to bladder, and our radiologists are really getting good at distinguishing the invasion of disease versus just edema. So, working with radiologists directly on developing the MRI is also very helpful.

Dale Shepard, MD, PhD: If you think about patients coming into clinics, who typically talks about these long-term consequences, survivorship issues? Is it typically the surgeon? Is it the radiation oncologist? The medical oncologist? Is it too often no one?

Laura Bukavina, MD, MPH: Most often, no one. Our time is so limited and there's such an overwhelming... There's so much information that has to be presented to a patient that even if that provider, whether it's a nurse practitioner or a surgeon, talks to them, in my experience, majority of patients do not absorb that information during their first visit. So, when you're telling them, "You're going to need surgery, chemo," those things are on their mind.

So, it's important to meet, not just and talk about it, not during that first visit, but at some time, once they have time to settle down, had time to have chemo, have multiple conversation with different multidisciplinary physicians, that's the time. So, usually I try to bring them in two, three weeks before their surgery and then have the conversation about the actual surgery. At the very first visit, you go over it and you provide them the information for the treatment plan, but really the nitty-gritty has to be a couple of weeks before.

Dale Shepard, MD, PhD: Makes sense. We were talking about sexual function. How about things in women like body image?

Laura Bukavina, MD, MPH: Yeah, conduit, which is the urostomy, is like an assault on female sexuality and female self-perception. Men as well, but I think females overall are a little bit more sensitive to the body image. It's all about frame of mind. Even if we're not able to offer alternative diversion options for patients, it's making sure that the patient has the necessary resources, social work, mental health, pelvic floor therapy, physical therapy, available to them and plugged in so when they do get that conduit and it changes their perception, their self-image, they're not paralyzed by it, but they have resources how to deal with it.

Dale Shepard, MD, PhD: When we think about ways that, you mentioned some differences in surgeries, what about the changes in reconstructive surgery?

Laura Bukavina, MD, MPH: The robotics is a huge benefit. Patients recover quicker. We have not gotten better at offering neobladder to female patients. There are still a lot of surgical, I think, improvement that could happen in that field. And we are actively working on making sure that females are dry. They're not only dry, but also the two problems is that if we try to rebuild a bladder, it's two options. Either they're dry because they can't pee, they have to catheterize themselves, or they leak. It's very little of that, the Goldilocks in the middle where you want them.

So, we are not quite there with the neobladder. I think there is room for improvement. In terms of the other reconstruction techniques, I think we've gotten our complication rates down. We have protocols for recovery in terms of ERAS protocols. I think that's pretty much the best it could be. It's the neobladder that we have some room to work on.

Dale Shepard, MD, PhD: When you talk to patients, how accepting are they of some of these more limited surgical approaches and their concern for effective surgeries? This thought that if we don't take more out, then it's going to come back. How do you address patient concerns from that standpoint?

Laura Bukavina, MD, MPH: Yeah, I think the point is not to over-promise, but be completely transparent and say, "This is always a cancer surgery. We will never compromise your cancer outcome by doing the surgery that we're talking about." And we always talk about that this actual plan might change depending what we actually find in the belly, but giving them the best case and the worst case scenario. And I think when patients hear the fact that this is always going to be a cancer surgery, this is always going to be about curing your cancer, but the second goal is to preserve as much of your quality of life as possible. Those things walk hand-in-hand. They don't take away from each other.

Dale Shepard, MD, PhD: When you think about... This is a really, really important area, but as you said, it's frequently not addressed. Clearly, people might listen and go, "We absolutely should be doing that," but the reality is patients don't mention it, docs don't talk about it. There's time components. How do you make it work?

Laura Bukavina, MD, MPH: You talk about it. Talk about it like we're talking about it now. You write about it. You make it acceptable. So, many of these patient organization, patient advocate organizations like BCAN, it's a huge topic that the patients are always talking about. So, patients discussing among themselves will make it acceptable for a patient to ask those questions. They sometimes feel ashamed, scared, uncertain if it's the right question, so making it okay to ask questions about organ preservation and sexual function.

Dale Shepard, MD, PhD: Yeah. If somebody's listening in and they want to think about starting a program to address this, what recommendations would you give?

Laura Bukavina, MD, MPH: I think reach out to the patients first. So, focus on patients. Ask them, "What could have been done better? What do you think would've helped you with your recovery? What resources you found helpful, which ones aren't?" And go from there.

Dale Shepard, MD, PhD: Perfect. What do you think is going to be the next break in terms of maybe a surgical technique or some way we manage patients that might improve their long-term quality of life?

Laura Bukavina, MD, MPH: I think bladder preservation overall is where we're currently trying to work in that space. We know that some patients can be spared the surgery completely if they have a great response to chemo, immunotherapy, or antibody drug conjugates, and that's where I think our field is going. It's not going to be everyone, but if we can spare the morbidity of surgery for some patients, that would be great.

Dale Shepard, MD, PhD: Fantastic. Incredibly important area.

Laura Bukavina, MD, MPH: Yeah.

Dale Shepard, MD, PhD: You're doing good work, and appreciate your insights.

Laura Bukavina, MD, MPH: Yeah. Thank you so much for having me.

Dale Shepard, MD, PhD: To make a direct online referral to our Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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