Empowering Providers to Empower Patients in Bladder Cancer Care

Dr. Nicole Rochester:

Hello, I’m Dr. Nicole Rochester and welcome to this Empowering Providers to Empower Patients podcast. Today we are exploring bladder cancer care, a field where scientific innovation is advancing at an unprecedented pace. Yet critical gaps remain in how the evidence is translated into everyday practice. Joining me today is Dr. Andrew Laccetti and a medical oncologist at NYU Langone Hospital in Long Island, New York, and the director of quality for hematology and medical oncology at Perlmutter Cancer Center. Dr. Laccetti brings extensive clinical expertise, a deep commitment to patient centered care, and hands-on experience in implementing innovations that bridge the gap between research and practice. Thank you so much for joining me today, Dr. Laccetti

Dr. Andrew Laccetti:

Thank you, Dr. Rochester. The pleasure is mine.

Dr. Nicole Rochester:

All right, so let’s jump right in. We’re going to start by talking about the landscape of bladder cancer and specifically focusing on the pace of innovation. Dr. Laccetti what makes bladder cancer care unique compared to other genitourinary cancers? 

Dr. Andrew Laccetti:

Bladder cancer is unique in a variety of ways. To take one step back, bladder cancer is a condition in which we actually can lump it into a larger bucket of tumors called urothelial cancers. So the urinary tract, from the renal pelvis down to the most proximal portion of the urethra, this portion of the urinary tract is lined in cells called transition cells, or more recently referred to as urothelial cells. Constantly being bathed in urine over our decades of lives, they have the tendency to be exposed to toxins, and that toxin exposure can predispose these cancers for cancer formation.  

Historically, bladder cancer has been regarded as a tobacco associated disease, and to a certain extent, it still is. But even in non smokers, we’re seeing the cancer occurring more frequently than before. It’s unique in that bladder cancer frequently occurs as a superficial tumor. So almost like a wart like growth that can occur along the urinary tract most frequently in the bladder. And often this can be addressed fairly easily with surgical procedures like Trans-urothelial bladder tumor resections or TURBTS. So inherent to that, a lot of cancer care actually comes outside of the oncology clinic.

So we’re factoring in urologists into the mix to really be the first point of contact for the management of bladder cancers. The other unique element to bladder cancer care is we’ve really seen an absolute shift and a rapid evolution in the standards of care not only for localized cancers, but metastatic diseases. So in the last five to 10 years, we’ve shifted our standards of care at least two or three times. So the rapid pace of involvement, the incorporation of non oncologic subspecialists, makes for a very, very unique tumor type.

Dr. Nicole Rochester:

Thank you for that. So with regard to that, are there specific recent innovations that changed the actual treatment journey for patients? 

Dr. Andrew Laccetti:

Absolutely. So we’ve developed newer therapies that allow for direct administration of medications into the bladder. Historically, early stage and superficial bladder tumors were managed with, again, a surgical removal through TURBT, maybe some intravesicular chemotherapy, and then BCG, which is actually the first immunotherapy developed, dating back into the ’70s and ’80s, BCG being essentially an inactivated formulation of tuberculosis, incites an inflammatory and an immune response within the bladder to prevent the development of future tumors. So we established this foundation, and over the last five to 10 years, newer intravesicular drugs have been developed. This has also been done in the context of a BCG, a BCG decline in availability. So we’ve kind of been forced into developing novel means to address the BCG shortage.

So that’s one aspect for localized cancer. In metastatic and advanced bladder cancers, we’ve found a dramatic evolution in access to newer and more effective drugs. Going back just five to 10 years ago, all patients in the metastatic setting would be given chemotherapy and really wouldn’t have other options available beyond that. But in the new immunotherapy era, we have new immunotherapies that have been approved for bladder cancer, as well as targeted forms of chemotherapy called antibody drug conjugates, in which we deliver an antibody that specifically targets the tumor and has a chemotherapy payload that is uptick directly into the cancer cell to help avoid some of the off-target effects of chemotherapy.

So the contemporary era of advanced bladder cancer actually incorporates a combination of an antibody drug conjugate and immunotherapy. And this now results in a treatment program that has a response rate of about 70%. And in the cancer world, where we’re routinely seeing good response rates of 30 to 40%, we have a remarkably effective treatment where we can say to patients in good faith, there is a better than not chance, a 7/10 chance you’re going to get this drug, it’s going to shrink it, you’re going to get treatment benefit, you’re going to feel better. And we’ve really entered an era that’s so far away from where we were even five to 10 years ago.

Dr. Nicole Rochester:

That is incredibly exciting, especially to hear that these advancements have happened just in the last few years. Thank you for sharing that, Dr. Laccetti . We know that bladder cancer affects everyone, right? But we also know that there are certain populations who may be more at risk for bladder cancer. And also there are certain populations where bladder cancer may go undetected and may not be discovered or diagnosed until later stages. Can you discuss who is most at risk for developing bladder cancer and the reasons why?

Dr. Andrew Laccetti:

Sure. So bladder cancer can affect all individuals.  It is typically diagnosed later in life and ’60s, ’70s and ’80s. As mentioned, historically risk factors have included tobacco. There’s also some linkage to some dyes such as certain hair dyes, benzene associated compounds. So there is an exposure component, but more often than not, there is not a direct lifestyle or exposure risk that we identify. It’s a disease that occurs just more commonly as patients get older. Certainly those at risk for having more advanced forms of the disease are those that have less access to care. The initial sign of bladder cancer is often painless blood in the urine. So painless hematuria. On occasion, we will see some lower urinary tract symptoms being a presenting sign, whether it be pain with urination, hesitance, more frequency. But if patients are letting these symptoms go unchecked, it can put them in a position where their cancer presents at a more advanced and less curable stage. And that comes along with access to care and it comes along even more so with access to subspecialists as a means to address these initial signs.

Dr. Nicole Rochester:

So as a result of some of those access barriers, do we see worse outcomes in certain marginalized or disadvantaged communities?

Dr.  Andrew Laccetti:

We do. So the primary link we see is a socioeconomic divide. So patients that are challenged to access healthcare based on socioeconomics, and actually geography, there’s been some interesting literature reported around rural populations having less equal access to urologists and the necessary diagnostic procedures. So for bladder cancer, it’s not as well studied, such as a racial divide. It appears to more closely relate to access to care, socioeconomics, and even a geographic component to where subspecialists are.

Dr. Nicole Rochester:

That makes sense. Thank you for clarifying that. So I want to move to talk about innovation. You’ve talked about some of the amazing things and some of the innovative ways that the treatment of bladder cancer has changed. So even with these new therapies available, what do you think prevents some healthcare providers from adopting them quickly?

Dr. Andrew Laccetti:

No, certainly. So bladder cancer is unique, as mentioned, because particularly in the earlier phases of the cancer, it’s a condition that is driven by urologists. Now, urologists come in a form where there’s a variety of degrees of specialization. There are some urologists that see everything, and then there are other urologists that focus specifically on cancers. Some urologists may only do bladder cancer. So what I found is that general urologists are very good with diagnostics, doing initial cystoscopies, tumor biopsies. But there is a level of comfort and a spectrum on which urologists are comfortable doing the actual tumor debulking procedure called TURBTs. 

Beyond that, urologists will have varying levels of knowledge and comfort in some of the intravesicular therapies, BCG, intravesicular chemo, and as mentioned, some of the newer, more targeted agents that are being used as intravesicular modalities. So understanding this variety and the spectrum of how general a provider is and their comfort level and their expertise in some of the procedures that are done is an issue. And it’s certainly a barrier that can be present for patients that don’t have access to specialists that are more familiar, not only with historical bladder cancer care, but also these rapid evolutions that I’ve said, which amongst the clinic where you’re caring for kidney stones, urinary tract infections, sexual health issues, the expectation to stay on top of tumor-specific details, it’s a lot. And it’s understandably challenging for a lot of doctors.

Dr. Nicole Rochester:

That is a lot. So how do we bridge that gap? What are the solutions so that urologists, like with this vast practice areas that you’ve talked about, how do we address that so that patients are receiving timely diagnosis and treatment?

Dr. Andrew Laccetti:

Yeah, I think this is a really wonderful question and a timely one. And not only is it a pertinent to urologists and bladder cancer, but I would argue amongst all specialty care, how are we bridging the generalist specialist divide? As a medical oncologist, I see this on a day-to-day basis where many of my partners are general oncologists. And I say to them regularly, I’m in awe of the practice of the generalist being responsible for hundreds of different tumors where I’m responsible for three or four. And I find it’s, in that context, it’s even overwhelming sometimes to keep up with the pace of change. So whether it’s a medical subspecialty, a surgical subspecialty, bridging this generalist to subspecialist divide is something that’s going to only become more important as care becomes more complex, care becomes more specialized. So I think the solution lies in having networks that are connecting specialists with their generalist counterparts. The patients are primarily seen by generalists regardless of the subspecialty in the United States. And this is going to continue to serve as the gatekeeper in the first pass for patients that are being diagnosed with new cases.

So tools to allow for either referral to more specialized doctors or urologists or otherwise, or even having maybe a support system outside of a direct referral, depending on some, particularly in the scenario where there can be geographic restrictions, whether it be a tumor board between specialists and generalist urologists, something like a virtual consultation. When it comes to procedurally based specialties, maybe there is an opportunity for surgical support in the operating room to overcome some of those specialty challenges. So I think the first key is to recognize the problem, educate providers on potential deficiencies in care delivery, and then doing our very best to bridge these divides that we see between more specialized and more general providers.

Dr. Nicole Rochester: 

That sounds amazing. It’s something that I think should be universalized in all of healthcare. I appreciate that. How do we bring the patients into this? How do we empower patients and their care partners to be active decision makers in their care, specifically for bladder cancer?  

Dr. Andrew Laccetti: 

So another great question, and I’ll kind of anchor this response around bladder cancer, which is very unique in that it incorporates many different specialists and pathways through a patient’s care can be very complex. For instance, patients that have more high-risk localized tumors, we refer to as muscle-invasive bladder cancer. Standards of care now include chemotherapy and a surgical removal of the bladder, or doing a combination of chemotherapy and radiation. So patients are seeing surgeons, they’re seeing radiation doctors, they’re seeing medical oncologists, and deciding amongst the specifics of treatment and scheduling these very complex and kind of stepwise treatment algorithms require a lot.

So patients need to be empowered, number one, to understand the decisions that are ahead of them. Not only what are the drugs and the surgical procedures, radiation strategies, but what are the side effects? What’s the timeline to which they are delivered? What are some of the limitations around the times of care? What are their side effects going to be? What will recovery times be like, particularly in the setting of surgery? So providing this information in as clear of a way possible, packaging the information within treatment programs and algorithms that they can help decide between, and then once decisions have been made, giving them the resources to move forward through these very complicated care pathways, using things like nurse navigators, administrative support that has an understanding of the timelines of said care. All of this comes together to really be a critical element for patients, supporting personalization of their care, empowering decisions, and then helping patients not feel so overwhelmed with the magnitude and the complexity of the plan that’s devised for them.

Dr.  Nicole Rochester: 

Yeah, I really appreciate that you talked about the overwhelm, because as I’m listening to all of this, I’m feeling a little bit overwhelmed about all of these options. Do you have any tips maybe for providers to tackle that, to really ensure that they’re presenting these options to patients and communicating them effectively so that the patients and their care partners actually understand all of that?

Dr. Andrew Laccetti: 

So although these treatments are complex, it’s our responsibility to simplify them as best as we can. First and foremost, it’s getting to know one’s patient, learning their degree of health care literacy, understanding their predilection to make decisions and be involved in their care. Once you have that background, it’s packaging the information in as digestible a way as possible. I found that by using diagrams, patient handouts, and trying to succinctly really lay out the options with visuals, it can help patients process things better. So for instance, if there’s a patient where I’m considering them between chemo and surgery or radiation, I may separate two pages on a page, say, this is the chemotherapy program, this is how we do it, this is what happens when you move forward to surgery. Underneath here are some of the side effects and the things to consider. So package it very clearly. Underneath that, say, here’s option B, here’s radiation, here’s how it works, here’s maybe the chemo I give along with it, here are some of the side effects you may not experience with surgery. So really trying to package and take the time so that you can outline complicated treatment programs in as simple of a way as possible.

And it can’t be understated that redundancy and revisiting the information multiple times is important for most patients. So follow-up visits, if you work with a mid-level provider, a nurse practitioner or a PA, having a follow-up call to address questions more intently, outline chemotherapy side effects, etc.  It’s leveraging our support services, meeting patients where they’re at, and realizing the value of revisiting and rehashing the information so that more is perceived and digested over time.

Dr. Nicole Rochester: 

Those are great, very practical tips. Thank you so much, Dr. Laccetti This has been a fascinating conversation. Just to summarize for the audience, we talked about bladder cancer landscape. We talked about the pace of innovation and how just in the last few years, there has been innovation such that there’s now a 70% response rate, which is phenomenal. We talked about some of the disparities in diagnosis and care, particularly among rural populations and those who don’t have access to some of the specialty care. We talked about the barriers in applying innovation and this idea of a lag between evidence and practice and how to empower patients and their care partners, how to state these options clearly using diagrams and other practical techniques and strategies. 

So this has been a very, very comprehensive conversation. I really want to thank you, Dr. Laccetti, for sharing your insights. And thank you to all of you who have tuned in. We are proud to present this podcast as part of the Patient Empowerment Network’s EPEP initiative, helping providers empower their patients every step of the way. I’m Dr. Nicole Rochester, and until next time, take care and be well.