Read the Full Video Transcript

Ashish Kamat: Hello everybody and welcome to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat, Professor of Urologic Oncology at MD Anderson Cancer Center in Houston, Texas. It's a distinct pleasure to welcome to the forum Professor Armine Smith, who's joining us from Johns Hopkins University in Baltimore. Armine, you and I talked a little bit at the AUA about this course that you hold, and of course, the importance of recognizing and understanding the nuances of care for women with bladder cancer, especially when it comes to organ preservation, sexual function preservation, and radical cystectomy, which believe it or not, is still not well recognized amongst the global audience or even in America for that matter. So really, I appreciate you taking the time, accepting our invitation, and sharing your insights with us today. So Armine, take it away.

Armine Smith: Thank you, Ashish. I'm so happy to have this opportunity to present the key insights from this course because this was a significant milestone at AUA, being the first of its kind course dedicated to exploring the female cystectomy in depth. So we had covered a few topics throughout this course, and I wanted to also kind of introduce my very wonderfully talented faculty, co-faculty, which included Amy Luckenbaugh from Vanderbilt University, who's also a urologic oncologist. We had Yahir Santiago-Lastra, who's the female pelvic medicine specialist from San Diego, and Maria Uloko, who is a sexual medicine specialist that is on her own in private practice. So throughout the course, we covered quite a few very important topics. One was the patient selection and preoperative counseling. We went into the anatomy and cystectomy techniques. So we discussed the urinary diversion choices for women, and we also had quite the segment dedicated to survivorship and post-cystectomy care.

The reason we wanted to talk about these topics at the urological associations meeting, because, number one, cystectomy itself is a fairly huge undertaking. And in the modern day, we have these risks that are spanning from preoperative patient selection, chemotherapy associated risk, the risks innate to the surgery itself, which is a technically challenging procedure, risks of recovery in the hospital, early and late. And the compilation of preoperative care we can do for our patients, especially women, would result in better patient selection and overall better outcomes. So we thought better counseling, which would minimize readmissions and complications, which would expose patients to sexual function implications of the surgery, and also have them think about the quality of life implications of the cystectomy would help with this whole process.

We also talked about better assessments, because a lot of the patients undergoing cystectomy are already older and more frail, so it's very important to assess these, kind of preoperative parameters, looking at gynecological history for women and pelvic organ status and prolapse status, sexual activity. Those are all these considerations that optimize the patient to undergo the right surgery. And it is really important in cystectomy, especially female cystectomy, because there are quite a few things that we are still struggling with as urologists. First and foremost, urology training is mainly in the male pelvis, and I'm a urologist who's been doing this for a long time and specialized in oncology, but I was still not even sure how to manage the rest of the female reproductive organs until I really started looking into this. And then the data shows over this past few years, we've started looking more and more, and how women are counseled and treated and bladder cancer. We do not do a very good job at counseling our female patients.

So one of the most important topics that comes up is the organ preservation. Typically, and going back to multiple years, bladder cancer in women was treated by anterior exenteration when the cystectomy was needed, meaning everything that was in the anterior area of the pelvis was removed. So women, we have the uterus, the ovaries, fallopian tubes, all the ligaments that keep the pelvic floor in place, and the nerves which are even less studied in women than they are in men. So all these things have been kind of overlooked.

So in the early 2000s, we started to give patients the options for pelvic organ sparing cystectomies, but even now, up to 40% of providers don't really tell the patients about the option for the pelvic organ sparing radical cystectomy. We do know those sparing organs improves functional outcomes, especially in women who have a neobladder, but also in other urinary diversions as well. And if the patients are selected properly, they have preserved oncological outcomes. So again, not a gynecologist, so we're less familiar with these numbers on the slide, but the lifetime risk for both uterine and ovarian cancer is fairly low in a woman that doesn't, let's say, present with abnormal uterine bleeding,

And we do not recommend asymptomatic screening for these women. And ovarian cancer, again, it's a very morbid condition, but the lifetime risk is very low, and we could screen out the appropriate patients and pick the ones who can keep their ovaries and instead remove fallopian tubes, that will reduce the incidence of fairly lethal ovarian cancer. So what complicates this whole scenario is we still don't have guidelines for patient selection for organ preservation. So our course had a clear agenda to help correct this knowledge deficit. We came up with the algorithm for patient selection for organ preservation, looking at the tumor characteristics and looking at the urinary diversion choices.

So you can look into nerve sparing and reproductive organ sparing and also urethral sparing surgery, and stratify patients depending on their premenopausal versus postmenopausal status, whether we're planning to do a neobladder or a different urinary diversion. And again, sexual activity and the type of the cancer and the stage of the cancer and the location of the cancer to pick the right patient for this. The other, kind of big topic, that we focused on as a multidisciplinary team was the survivorship. We know body image issues persist in women after stoma placement, and women become more vocal. So this is kind of an example of social media presence or media presence for women to admit having a stoma, things of that nature. So this is one of the issues in women. Another thing is the pelvic floor dysfunction. We know that up to 10% of patients can have vaginal prolapse and things of that nature. And then the female sexual dysfunction after radical cystectomy is fairly prevalent.

And again, we as providers don't know enough of it, but having involving multidisciplinary team of providers to take care of these patients really is paramount to improving the successes of the cystectomy. So the take-home messages from the course, where we have a huge potential from pre-rehabilitation to survivorship to improve outcomes for women with bladder cancer, and multidisciplinary approach sometimes is required. We want to increase awareness of the reproductive organ preservation because it improves the functional outcomes, preserves oncological outcomes. Again, just like anything in medicine, patient selection is the key to success. And then also there are known knowledge deficits in urologists and providers, and mid-level providers as well, including female pelvic anatomy and organ nerve preservation. Also post-cystectomy floor, pelvic floor, and sexual dysfunction in women. So these were my highlights from the course for you.

Ashish Kamat: So thank you so much, Armine, for sharing the highlights of your course with us. I have, I guess in some ways the advantage that my wife is a GYN oncologist, so I have had these sorts of discussions with her over the years, and I've been doing organ sparing for almost 20 years now, when appropriate as you mentioned, because as you mentioned, you want to select the right patient because if you have positive margins, then sparing the organs is really doing the patient a disservice. With that in mind, could you highlight for our audience a little bit, I know you showed the flow chart, but which patients would you not consider for organ sparing and vaginal sparing cystectomy in?

Armine Smith: Yeah, I think I'd like to break it down a little bit, per the organ that is to be spared. So if we look at patients to spare the ovaries. So women who have BRCA mutations, women who have a family history of breast and colon cancer, that can indicate some sort of a genetic component for increased ovarian cancer predisposition. Those would not be the women, or women who have any sort of ovarian abnormality at the time of the surgery that we pick up, or on the preoperative imaging, would not have their ovaries spared. And for the uterine and the vaginal sparing. So any abnormal postmenopausal bleeding can indicate some sort of uterine pathology. Again, that should be a conversation between the patient and provider as well. And any large bulky posterior tumors. Any patients who have hydronephrosis or any sort of involvement of the GYN organs, or palpable tumors, looking at the literature, would be not as good of a candidate for vaginal and organ sparing surgery, just because it may indicate reproductive organ involvement.

Ashish Kamat: And I think what you touched upon, which is shared decision making involves informing the patient, right? Because otherwise the patient can't really share in that decision making and it has to be patient-centric. One of the things that confuses us, and again, like you said, we have to listen to our colleagues in GYN oncology or OBGYN, is that the ACOG has shifted their recommendation in the last year as well. Previously the recommendation was spare the ovaries in everybody. Now there's again a shift towards saying, well, maybe the data that had been looked at to make that recommendation was not appropriate. And maybe if you're in there, in postmenopausal women, you should do an oophorectomy. So again, I think we need to stay tuned, like you said, and reach out to our colleagues in the discipline that is really specialized in this, and decide on whether ovary sparing makes sense or not. Currently, I still spare the ovaries even in postmenopausal women, unless they have the factors that you mentioned. So I think that's great. Ironically, through the World Bladder Cancer Patient Coalition, we did this global effort of 45 countries, asking patients and their carers what were some of the unmet needs and what were some of the big black holes in their care? And the one thing that came up repeatedly is exactly what you mentioned, which is a lack of preoperative counseling in women. Most women had not even heard about sexual function effects of radical cystectomy prior to radical cystectomy. Now clearly this was a global effort, and we like to think that maybe in North America we tend to counsel patients better than other parts of the world, but it's a globally deficient part of the care that we as urologists provide. So I'm glad you're bringing that up to the forefront. Have you implemented any activities or any outreach efforts to, sort of, educate our colleagues? And if not, how would you propose that we as a community do this? So we actually spread the word globally other than doing webinars like this?

Armine Smith: Yeah, I was just going to say I think this is what we're doing is great because hopefully more people can hear this. And I think we have a few initiatives including education of patients with bladder cancer, women with bladder cancer, looking at more of a global organ preservation and its effect on the survivorship. And I think hopefully when the word is out, I think sometimes the patients ask for it and actually patients make their providers more aware. But I think going through the advocacy networks and social media, I mean, that's probably the easiest way to get people nowadays, right? We're living in a different era.

Ashish Kamat: Yeah, that is so true. And I think BCAN does such a great job and Uro Today does too, with spreading the word and all of that. I think that's great. Armine, this is such an important topic. We could talk for hours, but clearly we won't. In closing though, I want to give you the last word. So high-level thoughts that you want to leave our audience with on this very important topic.

Armine Smith: Yeah, I think medicine is evolving. I mean, bladder cancer treatments have been evolving at this astronomical pace recently, and I'm just so happy to see this. But I think we can't forget the little things, including counseling, education, involving our patients in decision making, some things that we touched upon. And I think as providers, we just carry the burden of continuing to improve the care for our patients. And I think women with bladder cancer are very underserved, and I think we do need to give them our undivided attention.

Ashish Kamat: Yeah, no, very well said. Once again, I want to thank you for taking the time and thank you for doing all that you're doing with this very, very important cause. Thanks a lot, Armine.

Armine Smith: Thank you. Thanks for having me.