Keeping Your Bladder: Understanding the Risks and Rewards

October 19, 2026

Transcript

Voice over:

This is Bladder Cancer Matters, the podcast for bladder cancer patients, caregivers, advocates, and medical and research professionals. It’s brought to you by the Bladder Cancer Advocacy Network, otherwise known as BCAN. BCAN works to increase public awareness about bladder cancer, advances bladder cancer research, and provides educational and support services for bladder cancer patients and their loved ones. To learn more, please visit bcan.org.

Rick Bangs:

Hi, I’m Rick Bangs, the host of Bladder Cancer Matters, a podcast for, by, and about the bladder cancer community. I’m also a survivor of muscle invasive bladder cancer, the proud owner of a 2006 model year neobladder, and a patient advocate supporting cancer research at the Bladder Cancer Advocacy Network, or as many call it, BCAN, producers of this podcast. I’m pleased to welcome Dr. Ashish Kamat returning for his fifth podcast on Bladder Cancer Matters.

Dr. Kamat is an endowed professor of urology and cancer research and director of bladder cancer research at MD Anderson Cancer Center in Houston, Texas. He is also founding president of the International Bladder Cancer Group, the IBCG, and a member of BCAN Scientific Advisory Board.

Dr. Kamat’s expertise is in multidisciplinary management of urologic cancers with an emphasis on bladder and prostate cancer, organ sparing therapies, minimally invasive techniques, and bladder replacements like my own neobladder. A major focus of his research is to develop novel treatments for bladder cancer and identify resistance mechanisms and ways to overcome them. Dr. Kamat, welcome back.

Dr. Ashish Kamat:

Thank you so much, Rick. Always a pleasure to be here with you.

Rick Bangs:

We’re always thrilled to have you. So you’re getting what you’ve described to me as a steady stream of questions from patients and advocacy groups across the globe around this topic of bladder preservation and after neoadjuvant treatment. So I wanted to answer some of those questions today. And I’d like to start with which bladder cancer patients get neoadjuvant therapy and why?

Dr. Ashish Kamat:

Yeah, no, that’s a very good question. I think asking that question and our response will actually empower more patients to get the appropriate therapy. So a little background there, patients with muscle invasive bladder cancer or even certain non-muscle invasive bladder cancers that are almost invasive into the muscle, right?

So that’s a little bit of a false distinction, non-muscle invasive versus muscle invasive. But if there’s a risk factor for being muscle invasive and the patient only has local therapy, either in the form of radiotherapy or surgery, then you’re ignoring the fact that this tumor has likely seeded the patient’s bloodstream and lymphatic stream and there is a very high risk of recurrence that is not confined to the pelvis.

And because of that, over the years, patients have been counseled on getting therapy prior to the local therapy. [inaudible 00:03:10] we call neoadjuvant chemotherapy, but of course over the years there’s been advances in immunotherapy, smart chemotherapy such as ADCs, antibody drug conjugates. So now we actually just call it neoadjuvant therapy.

In today’s day and age, because the relative toxicity, they’re still toxic, but the relative toxicity has declined and the advantage to the patient as far as improving not just recurrences, but overall survival has really leapfrogged over the last two, three years data coming out.

In today’s day and age, I think every patient that is considering having their bladder removed or having radiotherapy for definitive local treatment, and the radiation oncologist use that word definitive, so I use that there too.

Rick Bangs:

Not my favorite term.

Dr. Ashish Kamat:

I know, Rick, and that’s why I said that, right? But I don’t want to disrespect our right on colleagues. So any patient that’s thinking of having local therapy should be also considering systemic neoadjuvant therapy. So short answer, any patient considering surgery or radiation therapy should talk to their urologist or radiation oncologist about, “Hey, should I also be getting systemic neoadjuvant therapy?”

Rick Bangs:

Okay. So how would you measure the results of neoadjuvant therapy?

Dr. Ashish Kamat:

Rick, as you know, being a survivor and I know being in the field, but of course taking care of patients and having this conversation over and over again, what matters to the patient varies based on the patient’s personal desires, their circumstances and cultural issues as well.

But across the board, most patients will tell me that yes, living longer with good quality is their prime objective. So let’s assume that that is the objective of most of our patients listening in today. They would like to live longer and still maintain quality of life. If that is the objective that you’re looking at, then the impact of neoadjuvant therapy on survival is the key metric.

And that is what has clearly in recent days been shown to be advantageous if a patient does get neoadjuvant therapy, either with enfortumab vedotin, which is an antibody drug conjugate plus pembrolizumab, which is a immunotherapy, or even gemcitabine cisplatin plus durvalumab, which is also known as the Niagara protocol, which may be all that patients in some parts of the world have access to.

Both of these regimens have shown a clear benefit with survival, which is a little bit different from some of the prior treatments where there was a minuscule benefit in survival. There was, but it was small enough that patients could say, “Hey, I don’t want to take the toxicity. I’d rather just go straight to local therapy.”

Rick Bangs:

Right. Right. Okay. So how accurately can you determine what is referred to as no evidence of disease and how do you use that concept?

Dr. Ashish Kamat:

So Rick, again, you and I have talked about this and we’re working on an endeavor together as to what do you really mean by no evidence of disease? Does it mean that there’s no cancer? Does it mean that the patient needs no monitoring? Does it mean the patient needs nothing to do with the medical system? I think in today’s day and age, no evidence of disease simply means that we cannot detect that there is cancer. It doesn’t mean that there’s no cancer. I think that’s an important distinction-

Rick Bangs:

Yeah, very important.

Dr. Ashish Kamat:

… people sometimes get lost in. So no evidence of disease with the limitations of what we have today. Say a patient gets neoadjuvant therapy and then they have some scans and the scans look great. There’s a misconception that, “Oh, my scans look good, so I have no disease.” No, it just means that the person may have disease, but we can’t pick it up on the scans. Or the patient might have a cystoscopy and a biopsy that is from one part of the bladder and the patient may say, “Oh, the biopsy was negative, so I don’t have cancer.”

And I think this is where we as a medical community and the advocacy group really has to make sure patients understand that no evidence of disease after new adjuvant therapy simply means that with the current tools that we have, we can’t detect that the patient has cancer. Now that doesn’t mean the patient doesn’t have cancer. And that’s why we in the community of bladder cancer experts across the board are working really diligently to try to identify with a very high accuracy what are the clinical parameters that we can use that truly correlate with no evidence of disease.

And that’s I think what you’re alluding to. So as you know, again, you were part of the effort, the International Bladder Cancer Group consensus effort, which we refined in Milan and which has been adopted by several agencies and clinical trials and SWOG and others, essentially says that if a patient gets neoadjuvant therapy and they have a negative MRI, which is the preferred modality for this definition, and they have a negative cytology, negative cystoscopy, negative biopsy, very important, and ideally negative ctDNA, which measures circulating tumor cells, then the patient could be considered to have a clinical complete response.

It’s not a guarantee that they don’t have bladder cancer in their bladder or elsewhere, but that’s the definition that is currently adopted and actually is being studied in a prospective manner to see if it truly is a robust enough definition that we can have a high level of confidence that the patient truly is NED. But right now, if a patient asks me, “Can you guarantee I have no cancer?” I’ll say, “No, no. I’m fairly confident if you hit all these metrics that you don’t have cancer and we still have to monitor things, but I can’t guarantee it.”

Rick Bangs:

Okay. So I want to bring home this concept of no evidence of disease, the seeding that you talked about, and really drive home the point as to why patients should get more therapy. So what kind of risk would make that necessary, getting that additional treatment?

Dr. Ashish Kamat:

Yeah, so that’s the thing. Again, it’s a very complicated discussion and I usually will talk to patients at length about this because it’s worth emphasizing. It’s not as though you can say, “Oh, today I don’t have cancer. Let me just go and continue to get monitored. And if the cancer comes back, oops, then you can take my bladder out or you can do radiotherapy or what have you.”

I think we as a field, if we get this wrong, we can go back to the drawing board and say, “Okay, let’s revisit the data.” But if the patient gets it wrong or we get it wrong on behalf of the patient, the patient risks dying, right? And that’s something we’ve learned over the years. The group out of Fox Chase did some elegant studies looking at really high molecular data profiling, selecting patients.

And lo and behold, there was no evidence of disease in the bladder and it was exciting, but I’m just going to simplify this based on our audience listening in without going into details, but patients that developed non-muscle invasive recurrence in the bladder, so not dangerous recurrence, but recurrence we normally would think, “Oh yeah, it recurred. We can treat this.” Then also develop metastatic disease, which means that there’s tumor cooking underneath the surface of the bladder and you can’t detect it and it could metastasize.

So I’m not saying that will happen with the current regimens we have. They seem to be very systemically more active, but we have to be cautious about that. And until we can prove it in a prospective manner, I emphasize telling patients that, “I’m willing to go with you on this journey, but you can’t disappear. You have to have regular follow-ups, regular checkups. It’s very important. And even then, even though if you were my family, I would recommend we monitor you closely. I can’t guarantee that I’m right or you’re right and that this may not come back with a vengeance.”

Rick Bangs:

Right. Okay. So I’ve got no evidence of disease. Let’s go back through what kind of treatment possibilities do I have and what kind of bladder preservation options in the two are kind of linked might there be as well?

Dr. Ashish Kamat:

If you get what’s known as the neoadjuvant therapy, and in today’s day and age, you get a little bit before, then you get the local therapy and you get some after. So it’s sandwich therapy, right? That’s another distinction worth making because sometimes patients hear, “Oh, I had the treatment and I had my bladder taken out. Why do I need more treatment?” And that was always part of the plan. Rather than giving say nine cycles of neoadjuvant therapy, which can be fairly toxic, we usually give four or three before, then do local therapy and then follow up with the adjuvant therapy based on the patient’s risk parameters.

So coming back to your question though, if a patient gets the early part of the treatment and then has no evidence of disease in the bladder, the standard is still to take the bladder out. That’s where all the data is. That’s the data that suggests the best long-term survival outcomes. And that is the only data that we actually can hang our hat on and tell the patient, “Yes, the study has been done and yes, this is what works.” Anything else is, in my mind, still experimental. Not that it may not be great, but we don’t have proof that it works. So what else can we do?

We can just monitor with cystoscopies imaging, as I mentioned. That’s one thing that is being studied. It’s just surveillance without additional local therapy, but then the patient does have to get additional systemic therapy to the full nine courses, or you can do something else locally other than removing the bladder. And what else can you do locally? You could do radiotherapy. Again, that is being studied. We don’t have proof that it is as good as surgery, but I suspect in well-selected patients it may be or we could do local therapy in the form of intravesical BCG if the patient has high grade recurrences, intravesical chemo, either alone or with delivery devices, which many of our listeners are well familiar with if they have different grades of disease.

So there’s a lot that can be done and a lot that is being studied, but we need to confirm with data that that is equivalent to the survival data that we have today with the therapy plus removal of the bladder.

Rick Bangs:

Okay. And then I just want to point out to our listeners that we’re recording this in the fourth quarter of 2026. So depending on when you’re listening, this might change, which isn’t a bad thing. Talk to me about the risks, kind of compare the risks of radical cystectomy and bladder preservation and how to weigh the difference between those.

Dr. Ashish Kamat:

Yeah, Rick, again, you’re a prime example of what happens when the patient makes an informed decision and is an equal partner along with their carers in that treatment decision, because there’s a misconception that removal of the bladder leaves the patient with a worse quality of life. That’s been shown in multiple studies to not be true so long as the patient chooses the particular procedure, the diversion.

Patients are very happy with the neobladder or a conduit or an Indiana pouch or whatever they choose. But it is a life changing procedure and there is morbidity involved with it. And across the nation, there’s about a two to 3% mortality. It’s less in high volume centers, but it does exist. So the patient always needs to be counseled on the fact that, “Yes, this surgery has a very high success rate. Yes, you have a good quality of life after surgery once you’ve healed, once the first one to three months, or maybe even six months with the neobladder is done, but it’s life changing and is life altering.”

And then you have to compare that and give the patient the data that goes with say bladder preservation with radiotherapy. Radiotherapy works. The immediate side effects are fairly minimal. We now have hyperfractionation where the patient doesn’t have to be stuck in say Houston if they’re here for four to five weeks. They could have it done in two weeks. Some are even pushing to have it sooner or shorter cycles. But if the patient is young and/or they have a bladder that’s already giving them a little trouble, so I said young because time toxicity builds up with radiotherapy or if their bladder’s already not functioning to its peak capacity, then radiotherapy can induce changes that decrease that quality of life. That is something that is a real possibility, right?

So patients need to be aware of that. Does it happen to everybody? Absolutely not. Does it happen to a significant number of people? It certainly does. So that’s one thing. The other is the continued monitoring with or without intravesical therapy. That does mean that the patient has to have the commitment and the ability to be tied to the urologist’s office every three months, maybe more often if they have a recurrence in the bladder that needs surgery, removal, intravesical therapy.

So oftentimes patients don’t recognize that. After surgery, if there’s PT zero, there’s no tumor in the bladder, then you just need a scan once a year and you could see your primary care physician in between. So some physician checks you every six months and that’s about it. You don’t need that constant monitoring, et cetera, et cetera, which also is a little bit of a time and an emotional burn. Some patients don’t mind that. In fact, they’re totally up to it and some are like, “Nope, that is not something that’s going to work for me. I want this cancer done with. I don’t want to have to worry that it’s going to come back in two or three years and until then constantly be stuck to the doctor’s office.”

So these are very detailed discussions that we need to have with our patients because ultimately, as with anything we do, everything is shared decision making, but I think the term shared decision making gets thrown about a little too casually. Patients are not given enough information for it to be shared. They need all the information.

Rick Bangs:

Right. Right. Okay. So I talk about the every three months option. So I went down bladder preservation and to your point, there’s a risk that maybe it wasn’t fully successful. So I’m on this every three months. So what are you doing in every three months and how long is every three months going to continue?

Dr. Ashish Kamat:

So every three months at the bare minimum, the patient should be having blood work, which would also include in the US at least we have access to this ctDNA. If there are international listeners listening in, ctDNA is not available in many parts of the world. Hopefully it will be at some point, but that’s what detects disease at a molecular level before we see it radiologically.

The patient also needs cystoscopy or biopsies, depending on what is seen in the bladder. They also need a cytology that’s fairly standard, available everywhere. And they need imaging. Now, MRI is something that has gotten to the forefront simply because it does have a little bit better resolution for recurrence in the bladder. But again, MRI is not feasible in many parts. Even in the US, it’s not easily accessible in many parts. So at least a CT scan, which is not as good as an MRI. So imaging, cystoscopy, blood work every three months. And you asked me for how long, we don’t know as of now.

So the current consensus is that at least for two years, every three months. After that, can we stretch it out to every four months? Maybe. Could we do six months? Maybe a little dangerous because if the tumor occurs between that three and six months and we don’t treat it, could it metastasize? Because remember, these patients started out with invasive life-threatening disease. They didn’t start out with non-life-threatening disease and the disease disappeared because of treatment. That treatment has been stopped.

So what’s to say that that patient’s tumor, if there was one or two, say 100 stem cells that have gone into migration, which again, many of the listeners might have listened to podcasts that you’ve done with some of the BCAN investigators, that happens, right? There’s dormal cells. There’s cells that go into what’s known as stem cell behavior. They’re laying dormant and that stimulus to keep them dead is gone and they could recur pretty rapidly and with a vengeance. So we have to be careful monitoring our patients. I would say as of now, at least two to five years of closed monitoring.

Rick Bangs:

Right, right. So at some point we’ll have more data on that, but at this point, this is where we are. Okay. Any final thoughts?

Dr. Ashish Kamat:

No, I want to thank you for allowing me to do this with you because I hope patients are listening and I hope they spread the word because these are questions that I think patients should ask of their medical oncologists, radiation oncologists, urologists, caregivers, everybody when they’re considering what to do next.

And if the patients are not fully informed, which I hope they will be after listening to your very, very comprehensive questions, they should reach out and get more information. It is a wonderful time that we have right now where our cure fractions have gone up, but we want to be a little bit careful and not over promise and under deliver. And I really want to thank you for doing this podcast.

Rick Bangs:

I think it’s great and it’ll answer a lot of questions. So Dr. Kamat, I want to thank you for answering some of those burning questions about preservation after neoadjuvant treatment. If you’d like more information on bladder cancer, please visit the BCAN website, www.bcan.org. In case people wanted to get in touch with you, could you share a Twitter handle or some other contact information?

Dr. Ashish Kamat:

Oh, absolutely. I mean, patients, I think it’s a good thing that they can just Google me and find all this information too, but they can certainly send me a note @UroDocAsh, which is my X handle. I’m on the BCAN website, of course, and they could reach out to me through my institutional MD Anderson email, which is [email protected]. Although I have to say our spam filters are pretty active, so if somebody sends it-

Rick Bangs:

Yeah, all that.

Dr. Ashish Kamat:

Yeah. If somebody sends it there, it may not get to me, but if they contact you at BCAN, you guys are really good at forwarding that information to me.

Rick Bangs:

Okay, thanks. Just a reminder, if you’d like more information about bladder cancer, you can contact the Bladder Cancer Advocacy Network at 1-888-901-2226. That’s all the time we have today. Please like, comment and subscribe so we have your feedback. Thank you for listening and we’ll be back soon with another interesting episode of Bladder Cancer Matters. Thanks again, Dr. Kamat.

Dr. Ashish Kamat:

Thank you, Rick.

Voice over:

Thank you for listening to Bladder Cancer Matters, a podcast by the Bladder Cancer Advocacy Network or BCAN. BCAN works to increase public awareness about bladder cancer, advance bladder cancer research, and provide educational and support services for bladder cancer patients. For more information about this podcast and additional information about bladder cancer, please visit bcan.org.