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>> Like every solid tumor,
bladder cancer comes in a low stage,
Stage 1, Stage 2,
and then later stages, Stage 3 and Stage 4.
The way that I think about this and the way that we use
a multidisciplinary approach to treat
bladder cancer with our surgical colleagues,
is really whether or not the tumor is invading into
the muscle layer of the bladder and that is Stage 2.
Those early stage tumors that are
carcinoma in situ or non muscle invasive.
A Stage 1 tumor are handled with
intravascular therapy or topical therapy
on the inside of the bladder,
or a Stage 2 and beyond,
it's a multidisciplinary approach between urology,
medical oncology, and sometimes radiation.
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>> Most patients with bladder cancer
find out that they have the disease because they have blood in
their urine and they seek care with either their primary
care physician first or directly to a urologist.
The biopsy that diagnosis bladder cancer is called a TURBT,
and that's done by a urologist.
Based on the stage,
a urologist will refer certain patients who meet
eligibility criteria based on their stage or
on their interest or comfort level with a medical oncologist.
I'm a medical oncologist and I give medical therapy,
both intravenous therapy as well as
oral therapy for bladder cancers.
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>> The current standard of care
for muscle invasive bladder cancer,
is for qualifying an eligible patient to
get a cisplatin-based chemotherapy prior to surgery,
and then go ahead and get surgery.
For certain patients,
we can actually incorporate chemotherapy with
radiation therapy to treat the bladder.
In the post-operative setting for patients
who've gotten preoperative chemotherapy
and we feel like they need
additional treatment based on the stage of the tumor,
for certain patients, we can offer
a post-operative immunotherapy that's
a new standard based on research done within the last year.
For patients with tumors that progress beyond
that perioperative therapy or
for patients who present with metastatic disease,
we have a variety of different kinds of treatments;
chemotherapy, targeted therapy,
which is an oral treatment,
intravenous immunotherapy called checkpoint inhibitors,
as well as a targeted
chemotherapy called antibody drug conjugates,
as well as other treatments on the horizon,
with clinical trials here at Hopkins and beyond.
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>> Bladder cancer tumors can
reoccur for non muscle invasive cancers.
It's a standard of care for urologists
to perform follow-up cystoscopies or looks inside the bladder.
Because a treated tumor can at
some point recur inside the bladder,
or actually even to the upper tracks that
comprise of the ureter and the renal pelvis,
which is the inside lining of the kidney.
In addition, those tumors could come back in the metastatic space,
particularly for patients though who
have a muscle invasive cancer.
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>> Our standard surveillance paradigm for patients with
a muscle invasive bladder cancer
who have gotten that aggressive logotherapy,
whether that's chemotherapy and
surgery or chemotherapy and radiation,
would be to follow them with imaging.
That's typically a CAT scan for most patients
every few months for the first few years after their diagnosis.
As time goes on,
we can lengthen the intervals between those scans as
the likelihood of recurrence goes down with time.
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>> The patients that we offer chemotherapy to,
are those with a high-grade muscle invasive bladder cancer
and also those who are fit for chemotherapy.
Both the disease and
the patient characteristics really have to combine.
Not all of our patients are
good candidates for our standard of care chemotherapy.
Because the current standard of care chemotherapy for
early stage muscle invasive bladder cancer
is the drug called cisplatin,
and that can have a lot of toxicity or
side effects that is not well handled by all patients.
It's impart while we're doing research to look at
other medications that may be used in that early setting.
For patients with later stage bladders cancer,
we consider alternatives like carboplatin,
immunotherapy, antibody drug conjugates,
as well as oral targeted therapies that can be used in sequence.
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>> In my mind, radiation therapy or local therapy that we can
use for bladder cancer has a few different indications.
The main one is for a minority of patients that have
a muscle invasive bladder tumor that is unifocal,
which means there's one tumor,
it's small, it's completely
resected by that trans urethral resection by
the urologists and there's
no indication that there's blockage of the ureters.
For those patients,
something called trimodality therapy where
the bladder can be spared is an option.
We do that as a part of standard of care as well as in
clinical trials here at Hopkins and across the country.
That's a clear indication for patients
who want to keep their bladder who have
a muscle invasive bladder cancer.
We also will sparingly use
radiation as a tool to treat some of our patients with
later stage disease who may have
a painful bone lesion or another lesion
that clearly may be amenable to
radiation therapy in addition to systemic therapy.
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