Occupational and Environmental Factors Linked to Bladder Cancer in High-Risk Groups - Sunil Patel
November 9, 2024
Ashish Kamat speaks with Sunil Patel about a BCAN Think Tank breakout session focused on occupational and environmental risk factors in bladder cancer prevention. The discussion explores the impact of exposure to burn pits among military veterans and environmental hazards faced by firefighters, highlighting the complex mixture of potential carcinogens including polycyclic aromatic hydrocarbons, heavy metals, and other toxic compounds. Dr. Patel stresses the importance of collaborative research efforts between urologists, epidemiologists, and basic scientists to better understand these risks, particularly through the examination of World Trade Center responder data and ongoing studies of exposure-related symptoms. The conversation underscores the need for detailed exposure histories, comprehensive questionnaires, and long-term population studies to advance understanding of environmental bladder cancer risks and develop effective policy initiatives.
Biographies:
Sunil Patel, MD, MA, Assistant Professor of Urology and Oncology, School of Medicine at Johns Hopkins, Brady Urological Institute, Baltimore, MD
Ashish Kamat, MD, MBBS, Professor of Urology and Wayne B. Duddleston Professor of Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, TX
Biographies:
Sunil Patel, MD, MA, Assistant Professor of Urology and Oncology, School of Medicine at Johns Hopkins, Brady Urological Institute, Baltimore, MD
Ashish Kamat, MD, MBBS, Professor of Urology and Wayne B. Duddleston Professor of Cancer Research, University of Texas, MD Anderson Cancer Center, Houston, TX
Read the Full Video Transcript
Ashish Kamat: Hello, everybody, and welcome once again to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat, Professor of Urologic Oncology at MD Anderson Cancer Center and President of the IBCG. And it's my distinct pleasure to welcome today Dr. Sunil Patel, who's joining us from the Brady Urological Institute. Dr. Patel, thank you for taking the time to join us today and share with us your expertise and insights on the topic of working smarter to prevent bladder cancer. Essentially, this was a breakout session, unraveling bladder cancer occupational and environmental threats at the recent think tank. And hopefully, this will translate soon into an actual working group. So looking forward to hearing what you have to say.
Sunil Patel: Thank you for the very kind introduction. And exactly what you said, so this breakout session that you're speaking about at the think tank was really focused on working smarter to prevent bladder cancer. We're really looking at the occupational and environmental hazards and risk factors. This has been an ongoing topic of conversation over the last several years amongst patients that we see in clinic, but also amongst BCAN as well. I'm trying to see what we can do to better understand the development of certain bladder cancers. I know we're seeing it more and more in our higher-risk population, which we'll go into a little bit, but also some of our younger patients as well. And so a lot of this is focused on those kinds of topics and really trying to get the wheels turning, so to speak, to really get the right minds together in the right room, so to speak, and to get this topic off the ground.
So the session really focused on, like we talked about, highlighting some of those key variables. And so the session was dedicated to the discussion of the intricate web of occupational and environmental factors that contribute to bladder cancer. And we really wanted to focus it on our high-risk population. So those were military veterans as well as firefighters. Firefighters have been deemed at the highest level of risk based on the EPA, based on their work exposures. And so we really wanted to look at those patients and those groups of people who are at the highest risk. We also wanted to highlight some of the burn pit exposures amongst the veterans. Burn pits are kind of notorious for the headlines, but a lot of us don't know what they are. So we're going to talk a little bit about what they are and what they really mean.
And really, by looking at the burn pits, we want to include the exposures of potential known carcinogens, as well as some that are theoretical carcinogens including PFASs, BPA, arsenic, certain pesticides which are organophosphates, dioxins which a lot of us know as Agent Orange. And also their potential impact on cancer development. And then we wanted to really tie this in and bring other people into the room. What I mean by that are bringing other areas of expertise such as epidemiologists. And so this session also looked at and sought out insights from our epidemiologists to provide some invaluable perspectives on study design and methodology, which is really crucial for tackling these complex research questions. And when you're studying certain topics like these, when you're looking at toxins, environmental exposures, you really have to think about not only certain dose-dependent variables or how much of toxin X, Y, or Z that someone was exposed to, but also for how long.
So there's also a time-dependent variable as well. And a lot of us who don't do epidemiologic work don't really understand that really well. And so having epidemiologists included in the discussion really helped us get a better understanding of how to study these patient populations. And then really the end goal is really to collaborate and generate actionable items and strategies for advancing the research in this field and potentially policy initiatives. And I know BCAN is working really hard on that as well. And really to ultimately improve identifying occupational and environmental risks for bladder cancer, particularly amongst the veterans and firefighters.
So we were very fortunate to have a urology resident from Texas, Dr. Shane Kronstedt, who was a military veteran and was a Navy SEAL. And he first told us about his first-hand experiences with burn pits. A lot of us, again, we see these in the articles and the headlines but we really don't know what they are. And having Dr. Kronstedt be able to really discuss and describe kind of what they are was very vital to the discussion. A, not only is his urology background and what he's doing in his research, but also personal first-hand experience. And so we see that greater than two million US soldiers are exposed to burn pits, fueled by really a jet propellant JP-8, which is highly toxic and flammable. And the rationale for burn pits is to get rid of waste. But by doing so, you release a lot of potential carcinogens and toxicants into the surrounding environment. And as you can see really highlighted in this photo quite well is there's no protective gear or these military personnel all wearing no masks, nothing really covering their body. And they are in this kind of close proximity of these burn pits, which they're definitely ingesting and inhaling and potentially touching these toxicants.
And so we really know that burn pits do release a high mixture of compounds such as polycyclic aromatic hydrocarbons, which are PAHs, furans, volatile organic compounds, heavy metals which potentially include arsenic as well, which has had some evidence recently for bladder carcinogenesis, lead, mercury, benzene, naphthalene. So there are a lot of compounds that we're learning more and more about what burn pits kind of what they mean and the potential risks. And then we also brought some people from the NIH who did a lot of work with the World Trade Center project, which was really focused on highlighting and looking at responders. Those people who were deemed either firefighters or police officers or other personnel that actually went into the buildings and helped do the cleanup and debris cleanouts, whether that was mainly focused on New York, but also other sites during the 9/11 attacks. But also looked at survivors. The survivors were deemed in a certain geographical region around those targets which potentially had an increased risk of exposure due to air, water, or any other type of exposure.
And if you look in this really nice graph they did, they certified 15 cancers and this was last updated in March of this past year. Non-melanoma skin cancer was definitely one of the highest, prostate cancer number two. However, if you see bladder is up there and you see about 644 among responders and 533 among survivors. And so there are conditions that we are seeing, and some of these personnel are significantly younger with no other risk factors to develop bladder cancer. And so it does highlight the potential need to study these a little bit more. And if you look at what the World Trade Center kind of cohort has really looked at, and they've done studies all across patient populations, not just in New York but also all across the US now patients have been moving around. They found that, again, similar to burn pits, heavy metals, PAHs, phthalates, including arsenic, have been really linked to the World Trade Center exposures. And they were able to deem that arsenic exposure was one of the highest risk factors for developing bladder cancer.
And being a firefighter as an occupation was one of the highest risk factors for developing bladder cancer as well. And then Dr. Sena, a pulmonologist up in the northeast, actually did a study and he does a lot of stuff with focusing a lot on breathing issues from our veterans. But is also kind of associated a lot of these inhalations due to burn pits from JP-8 and other exposures from inhalation from burn pits, and looked at that and translated into bladder cancer as well. And we did a recent study which showed 29% of the 155 respondents who were exposed to burn pits that were self-reported gross hematuria with no other risk factors, with a high AUASS symptom score about 12.25. And they did have high rates of lower urinary tract symptoms with frequency and urgency being slightly higher than in age-adjusted cohorts. And bladder, kidney, and lung cancers were amongst the top three with around 3.87%.
So it does show that there are some potential ramifications to these exposures. And Dr. Sena really stressed and a lot of us are trying to help him out, he has a lot of access to lung tissue. But he's trying to do a lot of very interesting work with mass spec and infrared to translate that and see if there's anything tied with bladder cancer and carcinogenesis, because he's been able to identify material in people's lungs that should not be there using this new infrared technology. And so during his talk of the session, really called a lot of us who do bladder cancer to help assist him with this research by potentially providing samples so he can better study the bladder tissue. And again, that really tied up the session with really talking about where we can help each other out. And our epidemiologists looking at our medical personnel outside of urology as well, looking at people who are working at the NIH and working at population-based studies. Even our trainees, Shane Kronstedt at Baylor with military exposure, talking about how we can do better for each other and help each other out.
And a couple of things that we really highlighted are, one is detailed history of exposure is key. A lot of us when we talk about risk factors, when we see patients and we're seeing new patients with bladder cancer, we really don't do a good job about that. And so teaming up with our epidemiologists will better allow us to create a questionnaire, so to speak, to help identify and key in on those exposures. And then again, collaborative efforts. I think that's the biggest thing about this session is understanding that a urologist can't do this study themselves. An epidemiologist can't do this study themselves. A population-based researcher can't do this by themselves, and the basic scientists can't do them by themselves. It's going to require a lot of us, and we need the patients and our military veterans and our firefighters.
And then additionally, not only do we have to figure out what's going on at the molecular level and cellular level, but we have to do population-wide studies as well. So this project will be something that happens over the course of 10, 15, 20, 30, 40 years or so, something similar happened with smoking. Not only is that going to have to go in parallel with the laboratory work, but we need to constantly identify what's going on and what we're finding in the lab and see if we can make changes in actuality, especially with policy changes as well. So at the end of our session, we really had a good idea and we had a good outlook in terms of who we need in the room and how we're going to do this. And so that was really the focus of this conversation, which was a very great conversation and inspired a lot of good questions. And a lot of questions that we still have left unanswered right now.
Ashish Kamat: Thank you so much, Sunil. That was a very comprehensive summary of the breakout session. Couple of quick questions, and I'm sure you guys have done this. So post the think tank, what all has the group done in order to move this forward and see things develop so that next year you guys have some concrete deliverables essentially?
Sunil Patel: Yeah, great question. So what we've been planning on doing is actually trying to get all the people that are interested in doing these types of studies. And so teaming up with our colleagues over at the NIH who are the epidemiologists who have a strong background in this type of research. And also teaming up with basic scientists who are doing actual research. So we had a recent meeting with Dr. Sena as well, as other key players about what are the next steps, how we can help at least his project out in utilizing his technology. Furthermore, we need to collaborate from our clinical side to our basic science or to the laboratory side. And working with people who you're very familiar with, like Dr. David McConkey and some others that develop potential models that we can kind of simulate some of these exposures. And so those are ongoing processes as well, which we're trying to get some funding off the ground.
But also trying to get some of those with some other funding to actually do some preliminary studies and really in some animal models, to see are we just seeing associations or we're actually seeing that these really have some element of carcinogenesis.
Ashish Kamat: Okay, great. So if any of the listeners are members, and obviously they have to be members of the think tank, but if anybody that's listening in wants to get involved, do you guys still have room for folks to participate? Should they contact you or should they contact BCAN, or what's the best way to get involved with this effort?
Sunil Patel: I would say the more the merrier. So this is one of those kinds of projects and studies which is really uncharted territory, and we have plenty of room for people to help out. What I've learned over the last several years when thinking about this project was trying to develop research studies on this is we don't know that much about this. But the person next to me may know a little bit of something more or something different or think about something different than I do or someone else. I think anyone who's interested, I'll be happy for them to reach out to me via email. We can share it or they can reach out to me on Twitter or X as it's now called, or even reach out through BCAN as well as Stephanie and everyone who are part of the BCAN leadership all have my contacts. And we're all very eager to try to get some more and more data so each year we can present more and hopefully have more answers.
Ashish Kamat: Great. Thank you so much.
Ashish Kamat: Hello, everybody, and welcome once again to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat, Professor of Urologic Oncology at MD Anderson Cancer Center and President of the IBCG. And it's my distinct pleasure to welcome today Dr. Sunil Patel, who's joining us from the Brady Urological Institute. Dr. Patel, thank you for taking the time to join us today and share with us your expertise and insights on the topic of working smarter to prevent bladder cancer. Essentially, this was a breakout session, unraveling bladder cancer occupational and environmental threats at the recent think tank. And hopefully, this will translate soon into an actual working group. So looking forward to hearing what you have to say.
Sunil Patel: Thank you for the very kind introduction. And exactly what you said, so this breakout session that you're speaking about at the think tank was really focused on working smarter to prevent bladder cancer. We're really looking at the occupational and environmental hazards and risk factors. This has been an ongoing topic of conversation over the last several years amongst patients that we see in clinic, but also amongst BCAN as well. I'm trying to see what we can do to better understand the development of certain bladder cancers. I know we're seeing it more and more in our higher-risk population, which we'll go into a little bit, but also some of our younger patients as well. And so a lot of this is focused on those kinds of topics and really trying to get the wheels turning, so to speak, to really get the right minds together in the right room, so to speak, and to get this topic off the ground.
So the session really focused on, like we talked about, highlighting some of those key variables. And so the session was dedicated to the discussion of the intricate web of occupational and environmental factors that contribute to bladder cancer. And we really wanted to focus it on our high-risk population. So those were military veterans as well as firefighters. Firefighters have been deemed at the highest level of risk based on the EPA, based on their work exposures. And so we really wanted to look at those patients and those groups of people who are at the highest risk. We also wanted to highlight some of the burn pit exposures amongst the veterans. Burn pits are kind of notorious for the headlines, but a lot of us don't know what they are. So we're going to talk a little bit about what they are and what they really mean.
And really, by looking at the burn pits, we want to include the exposures of potential known carcinogens, as well as some that are theoretical carcinogens including PFASs, BPA, arsenic, certain pesticides which are organophosphates, dioxins which a lot of us know as Agent Orange. And also their potential impact on cancer development. And then we wanted to really tie this in and bring other people into the room. What I mean by that are bringing other areas of expertise such as epidemiologists. And so this session also looked at and sought out insights from our epidemiologists to provide some invaluable perspectives on study design and methodology, which is really crucial for tackling these complex research questions. And when you're studying certain topics like these, when you're looking at toxins, environmental exposures, you really have to think about not only certain dose-dependent variables or how much of toxin X, Y, or Z that someone was exposed to, but also for how long.
So there's also a time-dependent variable as well. And a lot of us who don't do epidemiologic work don't really understand that really well. And so having epidemiologists included in the discussion really helped us get a better understanding of how to study these patient populations. And then really the end goal is really to collaborate and generate actionable items and strategies for advancing the research in this field and potentially policy initiatives. And I know BCAN is working really hard on that as well. And really to ultimately improve identifying occupational and environmental risks for bladder cancer, particularly amongst the veterans and firefighters.
So we were very fortunate to have a urology resident from Texas, Dr. Shane Kronstedt, who was a military veteran and was a Navy SEAL. And he first told us about his first-hand experiences with burn pits. A lot of us, again, we see these in the articles and the headlines but we really don't know what they are. And having Dr. Kronstedt be able to really discuss and describe kind of what they are was very vital to the discussion. A, not only is his urology background and what he's doing in his research, but also personal first-hand experience. And so we see that greater than two million US soldiers are exposed to burn pits, fueled by really a jet propellant JP-8, which is highly toxic and flammable. And the rationale for burn pits is to get rid of waste. But by doing so, you release a lot of potential carcinogens and toxicants into the surrounding environment. And as you can see really highlighted in this photo quite well is there's no protective gear or these military personnel all wearing no masks, nothing really covering their body. And they are in this kind of close proximity of these burn pits, which they're definitely ingesting and inhaling and potentially touching these toxicants.
And so we really know that burn pits do release a high mixture of compounds such as polycyclic aromatic hydrocarbons, which are PAHs, furans, volatile organic compounds, heavy metals which potentially include arsenic as well, which has had some evidence recently for bladder carcinogenesis, lead, mercury, benzene, naphthalene. So there are a lot of compounds that we're learning more and more about what burn pits kind of what they mean and the potential risks. And then we also brought some people from the NIH who did a lot of work with the World Trade Center project, which was really focused on highlighting and looking at responders. Those people who were deemed either firefighters or police officers or other personnel that actually went into the buildings and helped do the cleanup and debris cleanouts, whether that was mainly focused on New York, but also other sites during the 9/11 attacks. But also looked at survivors. The survivors were deemed in a certain geographical region around those targets which potentially had an increased risk of exposure due to air, water, or any other type of exposure.
And if you look in this really nice graph they did, they certified 15 cancers and this was last updated in March of this past year. Non-melanoma skin cancer was definitely one of the highest, prostate cancer number two. However, if you see bladder is up there and you see about 644 among responders and 533 among survivors. And so there are conditions that we are seeing, and some of these personnel are significantly younger with no other risk factors to develop bladder cancer. And so it does highlight the potential need to study these a little bit more. And if you look at what the World Trade Center kind of cohort has really looked at, and they've done studies all across patient populations, not just in New York but also all across the US now patients have been moving around. They found that, again, similar to burn pits, heavy metals, PAHs, phthalates, including arsenic, have been really linked to the World Trade Center exposures. And they were able to deem that arsenic exposure was one of the highest risk factors for developing bladder cancer.
And being a firefighter as an occupation was one of the highest risk factors for developing bladder cancer as well. And then Dr. Sena, a pulmonologist up in the northeast, actually did a study and he does a lot of stuff with focusing a lot on breathing issues from our veterans. But is also kind of associated a lot of these inhalations due to burn pits from JP-8 and other exposures from inhalation from burn pits, and looked at that and translated into bladder cancer as well. And we did a recent study which showed 29% of the 155 respondents who were exposed to burn pits that were self-reported gross hematuria with no other risk factors, with a high AUASS symptom score about 12.25. And they did have high rates of lower urinary tract symptoms with frequency and urgency being slightly higher than in age-adjusted cohorts. And bladder, kidney, and lung cancers were amongst the top three with around 3.87%.
So it does show that there are some potential ramifications to these exposures. And Dr. Sena really stressed and a lot of us are trying to help him out, he has a lot of access to lung tissue. But he's trying to do a lot of very interesting work with mass spec and infrared to translate that and see if there's anything tied with bladder cancer and carcinogenesis, because he's been able to identify material in people's lungs that should not be there using this new infrared technology. And so during his talk of the session, really called a lot of us who do bladder cancer to help assist him with this research by potentially providing samples so he can better study the bladder tissue. And again, that really tied up the session with really talking about where we can help each other out. And our epidemiologists looking at our medical personnel outside of urology as well, looking at people who are working at the NIH and working at population-based studies. Even our trainees, Shane Kronstedt at Baylor with military exposure, talking about how we can do better for each other and help each other out.
And a couple of things that we really highlighted are, one is detailed history of exposure is key. A lot of us when we talk about risk factors, when we see patients and we're seeing new patients with bladder cancer, we really don't do a good job about that. And so teaming up with our epidemiologists will better allow us to create a questionnaire, so to speak, to help identify and key in on those exposures. And then again, collaborative efforts. I think that's the biggest thing about this session is understanding that a urologist can't do this study themselves. An epidemiologist can't do this study themselves. A population-based researcher can't do this by themselves, and the basic scientists can't do them by themselves. It's going to require a lot of us, and we need the patients and our military veterans and our firefighters.
And then additionally, not only do we have to figure out what's going on at the molecular level and cellular level, but we have to do population-wide studies as well. So this project will be something that happens over the course of 10, 15, 20, 30, 40 years or so, something similar happened with smoking. Not only is that going to have to go in parallel with the laboratory work, but we need to constantly identify what's going on and what we're finding in the lab and see if we can make changes in actuality, especially with policy changes as well. So at the end of our session, we really had a good idea and we had a good outlook in terms of who we need in the room and how we're going to do this. And so that was really the focus of this conversation, which was a very great conversation and inspired a lot of good questions. And a lot of questions that we still have left unanswered right now.
Ashish Kamat: Thank you so much, Sunil. That was a very comprehensive summary of the breakout session. Couple of quick questions, and I'm sure you guys have done this. So post the think tank, what all has the group done in order to move this forward and see things develop so that next year you guys have some concrete deliverables essentially?
Sunil Patel: Yeah, great question. So what we've been planning on doing is actually trying to get all the people that are interested in doing these types of studies. And so teaming up with our colleagues over at the NIH who are the epidemiologists who have a strong background in this type of research. And also teaming up with basic scientists who are doing actual research. So we had a recent meeting with Dr. Sena as well, as other key players about what are the next steps, how we can help at least his project out in utilizing his technology. Furthermore, we need to collaborate from our clinical side to our basic science or to the laboratory side. And working with people who you're very familiar with, like Dr. David McConkey and some others that develop potential models that we can kind of simulate some of these exposures. And so those are ongoing processes as well, which we're trying to get some funding off the ground.
But also trying to get some of those with some other funding to actually do some preliminary studies and really in some animal models, to see are we just seeing associations or we're actually seeing that these really have some element of carcinogenesis.
Ashish Kamat: Okay, great. So if any of the listeners are members, and obviously they have to be members of the think tank, but if anybody that's listening in wants to get involved, do you guys still have room for folks to participate? Should they contact you or should they contact BCAN, or what's the best way to get involved with this effort?
Sunil Patel: I would say the more the merrier. So this is one of those kinds of projects and studies which is really uncharted territory, and we have plenty of room for people to help out. What I've learned over the last several years when thinking about this project was trying to develop research studies on this is we don't know that much about this. But the person next to me may know a little bit of something more or something different or think about something different than I do or someone else. I think anyone who's interested, I'll be happy for them to reach out to me via email. We can share it or they can reach out to me on Twitter or X as it's now called, or even reach out through BCAN as well as Stephanie and everyone who are part of the BCAN leadership all have my contacts. And we're all very eager to try to get some more and more data so each year we can present more and hopefully have more answers.
Ashish Kamat: Great. Thank you so much.