“Setting Expectations Up Front”: Collaboration on Guiding Patients Through Treatment Experience

In the final segment of this roundtable on NMIBC, Drs. Chang, Qin, Jayram, and Bourlon discuss the physician-patient experience, and each panelist provides details on how they manage guiding their patients through the treatment experience.

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Sam Chang, MD, MBA:
I think you’ve touched in a really key point that we probably under emphasize and under utilize is setting expectations up front. That whole idea of, “This is what’s going to happen likely. This is what you need to be prepared for.” So those types of cheat sheets that you’ve set up, individuals say, “What’s your strategies?” And I’ll turn to our advanced practice providers and I’ll say, “Marin, what do we do?” And it’s because they’ve set up strategies just as you’ve outlined that they know. What do they do? Examples, they’ll initiate anticholinergic, beta-three agonist therapy, mirror-bear ground, different things, prior to any type of treatment. They’ll get that on board early on. Now sometimes we’ll have insurance issues, but they’ll start that.

They’ll start the oral peridium, again, ahead of time. All these, especially in individuals who have already shown a predilection to having significant urinary tract symptoms. But then you throw in other little tidbits. Supposedly, I don’t know if this is true or not, BNO suppositories are now supposedly now available again. Belladonna and opiate. So people as old as me, remember we gave those all the time, suppositories. They haven’t been available for years, but that ability to help relax intrarectal valium, again, something that we don’t normally give, again can help many of these individuals as they get different types of treatments and those types of things.

So setting expectations I think is really important and setting up strategies regarding that. As you look then at integrating different types of treatment options, Dr. Qin, when you talk with your urologists and as they go through different clinical trials, how do you determine which clinical trial to open? There are so many. There are so many exciting medications, exciting delivery systems, exciting companies. How do you help determine which studies we’ll focus on?

Qian Janie Qin, MD:
Yeah. Well we’re very unfortunate that our urologists are so excellent. So for the non-muscle invasive space, they really head-sphere the clinical trial paradigm. But in general, both in the localized setting and in the more advanced setting, we certainly look at the trial portfolio that we currently have. What are we missing? What disease type can we really bring in a trial that could be impactful in terms of what we can offer to our patients? And not overcrowding a particular space to where there’s multiple trials that is available. Then the question is, which one do you choose and can you actually get patients onto those trials?

And so I think in general when we look at our trial portfolio, it’s really having a variety of good treatments, whether it’s localized or systemic, so that at every stage of disease we have clinical trial options to offer patients. We always have standard of care, but we also have these maybe novel agents, maybe novel combinations, maybe phase ones first in human to offer patients who are interested in trial enrollment because at the end of the day, that is how we advance care, like the TAR. And so that’s kind of how we function is making sure that we’re having that variety for patients.

Dr. Chang:
And Dr. Bourlon, how in Mexico City do you integrate, you mentioned that you work well with your urologist, how do you all integrate and evaluate and see these patients and then determine either treatment or clinical trial?

Maria Teresa Bourlon, MD, MS:
Yeah. So I think it has been a work of years as urologic oncology clinics are earlier than what we know for breast cancer or lung cancer that have been clinics going on for decades. So we try to work together and we have a urologic oncology meeting each week in which we discuss difficult cases. We discuss whether there’s a trial available or not, whether the patient needs to go with standard therapies, available therapies, what we have access to. So that’s the way we mainly do it. We have the case, we discuss the case. We have urology, radiation oncology, medical oncology, and any other service that might be needed for that specific case.

So that’s the way we do it and we also try to focus on supportive care. Many of these patients come along with a lot of side effects, especially in the bladder, a lot of pain. So oftentimes we need palliative care or pain medicine to be involved in the case because I kind of recall some patients saying, “I’m not undergoing any other intravesical therapy because of the pain.”

Dr. Chang:
Understood.

Dr. Bourlon:
And those are the kind of patients I usually think for systemic therapy rather than intravesical because I still, we are back to the beginning with the SunRISe study. We think this is a local disease, why to add a systemic therapy if the response rates are very low and we’re seeing better responses with intravesical therapy? So in my mind, it’s mainly very bad bladder toxicity, the reason for considering systemic therapy such as immunotherapy.

Dr. Chang:
Yeah. Really good points. With the last few minutes we have, I’ll ask each of you in a minute, kind of give us your highlights and then your next steps of what we’re going to do or what’s exciting out there. So we’ll start off with an important highlight and then next steps. So I’ll make it easy. I’ll start off with me. Okay. Highlights. So much activity going on in non-muscle invasive bladder cancer. Next steps. So much going on in non-muscle invasive bladder cancer and that’s really important because we have now a focus on this disease process. We have options, not only approved, but also clinical trial wise. So Dr. Qin.

Dr. Qin:
Yeah. So highlight, I certainly think the TAR-200 data. So RISe-1 is very exciting. I think next steps, from a medical oncologist perspective, it’s really what’s the role of our systemic therapies in the non-muscle invasive bladder cancer realm, whether it’s given systemically or can we bring some of those novel agents into the intravesical space?

Dr. Chang: 
Right. Dr. Jayram?

Gautam Jayram, MD:
Yeah. Highlights, BCG unresponsive options that we just didn’t have before. And really a cystectomy is great and it’s a very good oncologic tool in the right patient, but it takes a big toll on patients and their families. And 50 years from now I’ll be interested to see surgically what the diversions are for bladder cancer. Are they still utilizing bowel and the morbidity associated on those of us that do it a lot? Just you think about that and you’re like, “Well is there a better way to do this?” But until then, this is really, to me, one of the best ways forward is to try to avoid cystectomy in those patients that may not need it right away.

And then what’s next? I’m really interested in genomics in bladder cancer and how we can, we’re seeing some of this in advanced disease with CT DNA, now we talked about FGFR in low-grade disease, but I think there’s really even an opportunity to do some profiling of tumors in NMIBC. And I hope to envision a time where every TURBT gets sent off for a genomic test and then we base our therapies based on that result.

Dr. Chang:
Right. Dr. Bourlon?

Dr. Bourlon:
Yeah. So I think non-muscle invasive bladder cancer is a population with unmet needs. Unfortunately, we’re living a time where they have more options, not only cystectomy. So that’s something really promising. Looking forward, I think we would love to see an algorithm, which patient is better for one therapy or the other? Is he having this mutation and then because he had this mutation, they can go to this treatment or they’re having very bad urine toxicity so they’re better candidates for systemic therapy. So I envision the feeder with an algorithm of which is the best therapy for each patient and I’m hesitant to see whether we can do sequencing, right, because we have the response rates for first line.

If we’re going to give one therapy on second or third line, what’s the response rate and what’s the efficacy of that? Is that even safe? So I’m thinking we’re going to be seeing sequencing therapies and they might be sequencing studies in the future. And I’m also eager to see what’s going to see as complete response, not at 12 months, but two years, three years because immunotherapy usually done gives you systemically big early responses, but it’s usually on the long-term that you see benefit of filing immunotherapy. So I’m curious about how those curves are going to look five years after exposure to pembrolizumab or cetrelimab. So that’s what I’m curious about in the future.

Dr. Chang:
Well I want to thank the panel. Obviously real experts here. Different perspectives, different options, and honestly, a lot of more hope for our patients with non-muscle invasive bladder cancer. So thanks to all of you very much.