Many factors can impact bladder cancer treatment choices—from the cancer’s stage and risk level to your overall health, daily life, and personal preferences. Bladder cancer expert Dr. Ashish Kamat reviews the treatment approaches available, including surgery, chemotherapy, immunotherapy, and radiation, and he emphasizes why sharing your goals and health concerns with your care team is essential.
Dr. Ashish Kamat is a Urologic Oncologist and the Director of the Bladder Cancer Support Program at University of Texas MD Anderson Cancer Center in Houston, Texas. Dr. Kamat also serves as the founding President of the International Bladder Cancer Group (IBCG). Learn more about Dr. Kamat.
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Transcript
Katherine Banwell:
Dr. Kamat, would you walk us through the factors that are considered when choosing therapy for bladder cancer?
Dr. Ashish Kamat:
Yes, absolutely. And it sort of alludes to what I mentioned earlier: the goals of treatment. So, what is the goal of treatment for a patient? Obviously, you assume patients want to live, so overall survival, best efficacy of the treatment if it’s noninvasive, invasive, metastatic. That is clearly the important factor. But there are other factors that go in too when you’re choosing the treatment.
Because you can get survival, and this is just hypothetical. You can get survival that’s five years without your bladder, or you can get survival that’s three years with your bladder in place. So, you have to inform your physician what’s really important to you. You also have to inform your physician if there are any life events that are coming up because if there’s a treatment that cannot be delayed whatsoever, we will tell you, but if you have a major life event, say a graduation coming up, you need to wait for X number of months before you get intensive therapy, there are other treatments that can be started that can give us the time safely in order to get you to do that thing.
But once that’s done, and that’s the social aspect of things, what we really look at, and what a patient should be asking their physician, is: Based on my risk category, am I noninvasive, am I muscle-invasive, am I metastatic, and within each, what is my risk category? Now, just by definition, once you are muscle invasive or metastatic, it’s automatically all high-risk, and your treatments depend upon the histology and stage of cancer.
If you’re non-muscle-invasive, then the treatments depend on the grade and stage of tumor and the risk categorization. So, it’s a very complex decision. It’s not something to be taken lightly, but those are all the things that we factor in, and a patient should be factoring in when they’re choosing treatments. And last but not least, it’s the toxicity profile, because now, for example, we have five different agents that we can use for patients that have had a nonresponse to standard immunotherapy in the bladder. And some of them are given once every three months, and they work, say, 25 percent of the time. The others are given almost every other day, and they work about 50 percent of the time.
But I’ll have patients who tell me, “You know what? Let’s try the less intense one first. If it doesn’t work, then I’ll go to the next treatment.” On the other hand, patients will sometimes say, “Throw the whole kitchen sink at me. I want the one that has the best results. I don’t mind if I have to live in the hospital.” So, that’s the other thing that we really have to factor in.
Katherine Banwell:
What about comorbidities? What role do they play?
Dr. Ashish Kamat:
Oh, that’s a huge role, and that’s what I mentioned earlier about toxicity. So, if a patient has certain comorbidities, we know about those, of course, and if the patient has certain issues such as cardiac dysfunction or renal dysfunction, we factor that in when it comes to the management of patients. But if there are comorbidities that are not medically visible, but the patient has trouble at home with daily activities of life, so on and so forth, that’s something the patient absolutely needs to let us know, so we can factor that in. A simple example is a patient with maybe early stages of Parkinsonism.
If we don’t see that when they’re in the office with us, we might recommend a treatment that is very dependent on manual dexterity, and the patient just can’t do it at home. So, if they can’t do it, they don’t get the treatment, and we’ve only seen them for 30 minutes, and they haven’t revealed that to us because it’s not a full-blown issue. So, it’s very important to reveal all of your comorbidities to your treating team.
Katherine Banwell:
Would you share an overview of the types of therapy for bladder cancer? You mentioned immunotherapy. What else is available?
Dr. Ashish Kamat:
Yeah, there are many different treatments for bladder cancer, and the buckets to sort of look at that are either surgical, drug-related, or radiotherapy. That’s a broad bucket to look at. And when it comes to bladder tumors, the diagnosis is confirmed by removing or accessing the tumor. So, that’s the most important surgery that any patient with bladder cancer ever goes through. And because oftentimes it’s considered a biopsy the first step, it’s not given the importance that needs to be given. The TURBT, or transurethral resection of bladder tumors, is often done by the junior-most person or someone who’s not really invested in the diagnosis.
So, that, by itself, if it’s done correctly, is a treatment. There are many tumors where if you do the biopsy resection, the patient doesn’t need any other treatment. So, that surgery is very important. Then, we go on to adjuvant therapy for the non-muscle-invasive, which includes chemotherapy and immunotherapy, and these are treatments usually that are put in the bladder. They work in two broad categories: Chemotherapy essentially kills cancer cells that are present, and this can be delivered directly in the bladder or using certain devices that are put in the bladder that release the chemotherapy at a slower rate. And then you have immunotherapy.
In immunotherapy, the most effective immunotherapy for non-muscle-invasive bladder cancer is actually the BCG vaccine, which was developed against tuberculosis many, many years ago, but it really has the highest efficacy of any known immunotherapy for any cancer, period. It works really well on the bladder. And then there are other immunotherapies, such as gene therapies and others that stimulate local immunotherapy in the bladder for different types of cancers. Now, if you take this paradigm, you can apply it to all the stages of bladder cancer.
And you can have surgery for muscle-invasive disease where the bladder is removed, and you make a new bladder for the patient. You can have immunotherapy, which is injected into the bloodstream, again, which has really changed the management of patients with bladder cancer, and chemotherapy, either general chemotherapy or what we call smart bomb chemotherapy where they’re attached to certain antibodies and they try to hone in on the cancer. It’s not for every patient because it can have toxicity in others, as you asked earlier, but it is an option for the appropriate patient that is always discussed.