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>> So bladder cancers
come in many different shapes and sizes.
The way that we typically think about bladder cancer
is being non muscle invasive or muscle invasive
and what that actually means
is if you think about bladder tumor
like a piece of broccoli growing into the bladder.
We actually don't care too much
about the size of that flower
and similarly the stem doesn't have much meaning.
All we care about are the root system from that broccoli.
Are the roots going deep into the bladder wall,
into the muscle of the bladder,
or are they more superficial
just invading either the first lining of the bladder
or not invading at all?
And that's really what matters
in terms of what kinds of recommendations
we'll make to patients and their family members
about the best options in treating their bladder cancer.
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The traditional thinking is that bladder cancer
is a disease of aging
and when you look across 100 patients, that's very true.
The average age of a patient with bladder cancer
is typically in their early 70s,
but one of the things that I think is underappreciated
is that younger people do get bladder cancer.
And similarly, well, two thirds of bladder cancers
maybe among men, women also make up a significant proportion
of patients with bladder cancer.
Many people are under the impression
that all bladder cancers is due to smoking
and actually that's not the case.
Around 40% of bladder cancer is attributable to smoking,
but that means that the vast majority of bladder cancers,
more than 60% are completely unrelated.
For that other 60%, a small proportion
it may be due to other environmental exposures,
workplace exposures, for example,
people that worked in factories,
specifically with dyes and other chemicals,
but for the majority of these patients,
we don't yet quite understand
why they developed bladder cancer
and that's a question we get quite often.
Why me, why have I gotten that diagnosis?
And the truth is that the majority of the time
the honest answer is we don't know yet.
Now, this is something that we're looking at very closely
and one of the reasons why we're very interested
in for example, doing genomic sequencing
of the vast majority of patients
that walk through our doors with bladder cancer,
is to understand what are the commonalities
among these patients
and what can we learn in terms of genuine both environmental
and maybe familial risks factors?
(somber music)
It's very interesting,
there's probably around a single digit percent
of bladder cancers that can be attributable
to some type of family history.
There are some cancer syndromes
that can be associated with bladder cancer,
but the vast majority of bladder cancers
are not related to a family history.
And probably what's going on
is what we think of as a two hit hypothesis,
which is somebody has some risk factor
that they're born with for developing a bladder cancer
and then there is a second hit
of some environmental exposure that may be subtle
that may combine to then give them that cancer.
So it's probably a multifactorial.
There's probably more than one reason
why they're developing that cancer,
but most likely less than 5% or so
is actually due to a family history.
(somber music)
Typically, a patient is diagnosed with bladder cancer
either by having blood in their urine,
a term we call hematuria,
or by finding a mass on their bladder
through some other diagnostic means,
for example a CT scan or an ultrasound might pick up a mass.
And then from there, a urologist will directly visualize
the tumor in their bladder,
that's called a cystoscopy,
and then they will typically take them
to the operating room
and under anesthesia, remove the mass.
That is both diagnostic and therapeutic.
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The prognosis for a bladder cancer patient
depends very closely on what stage they are.
So how deep does the bladder tumor invade into the muscle?
What is the status of the lymph nodes in the body?
Does it look like there's cancer in those lymph nodes?
And is there evidence of cancer in other parts of the body?
And taken together, those three things,
the tumor, location and depth,
the T, the nodes involved, the N,
and whether there's other sites of disease, that's the M,
is called the TNM staging.
And that really allows us to understand
and determine the prognosis.
(somber music)
So we are truly at a crossroads
in bladder cancer care today.
One of the reasons for that
is there have been multiple new therapies
that have been FDA approved for advanced
and metastatic bladder cancer.
Similarly, we have started to see new drug approvals
for non-muscle invasive bladder cancer.
And that's really exciting because, for example,
five or 10 years ago,
I really only had one or two therapies
to offer my patients newly diagnosed with bladder cancer.
But today, I'm able to offer them
a multitude of different therapies
and also able to offer them innumerable clinical trials
that we have available that may be the next latest
and greatest thing tomorrow.
(somber music)
So one of the things that we try to do at Johns Hopkins
is assess what the patient's goals of care are
and what the patients and their family members want.
So for example, muscle invasive bladder cancer
can be treated with removal of the bladder
typically, with chemotherapy beforehand,
but there are alternative options
that can be equally beneficial in certain cases.
One of those is called trimodality therapy,
which is combination of radiation and chemotherapy
with close surveillance of their bladder by urologist.
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So the concept of genomic sequencing
is that we can take a patient's tumor
and identify all of the abnormalities
that have caused that patient's cancer.
So the genes that should be normal
and have somehow been subverted
in that patient's bladder cancer,
we can actually identify which genes are mutated
or made abnormal.
And why is that important?
It's important for multiple reasons.
First of all, it allows us to understand
the origins of their cancer.
But more importantly,
now we actually have multiple therapies
that have been FDA approved
that are based on specific gene mutations
and that alone is extremely inspiring,
exciting, all of these things
because it allows us to tailor certain therapies
for patients specific genomic subtype
and that's really exciting.
(somber music)
There's a few reasons why I think
that the bladder cancer care here at Johns Hopkins
really is a center of excellence
and one of those reasons
stems on our multidisciplinary care.
I work very closely with our medical oncologists
and radiation oncologists, oftentimes in the same workspace
and I'm constantly discussing my patients with them.
And so, for example, when a patient comes for a new visit,
if we know in advance that they have, for example,
muscle invasive bladder cancer,
oftentimes they'll see both myself, a urologist,
and a medical oncologist on that same day.
So that's number one.
Number two, is that I truly believe
that we offer tomorrow's therapies today.
And what I mean by that is we have at our disposal
clinical trials in really every disease space
within bladder cancer.
So whether you're diagnosed with the earliest stage disease
or the latest stage, it doesn't matter,
we are going to to have a therapy
that may be standard of care,
but we'll also have therapies on trials
that are very likely to be promising
and be tomorrow's therapies.
And then thirdly,
we are also actively involved in discovery.
And so not only are we evaluating new therapies
through clinical trials,
but we're actually making those discoveries
in the laboratory.
And so we are oftentimes gonna be the first ones
to offer new bladder cancer therapies
and new bladder cancer diagnostics
to our patients because we're the ones developing them.
(somber music)