Transcript of Bladder Cancer and Aging: Navigating Challenges and Prioritizing Care

June 27, 2023

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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. This podcast is sponsored by the Seagen/Astellas Alliance. I’m pleased to welcome today’s guest, Dr. Sarah Psutka. Dr. Psutka is a urologic oncologist specializing in bladder and other genital urinary cancers at the Seattle Cancer Care Alliance. She’s also associate professor of urology at the University of Washington School of Medicine. Dr. Psutka is also one of two recipients of BCAN’s first ever Translational Clinical Trial Award, a TCTA for her Get Moving Clinical Trial. That trial will enroll patients who have muscle invasive bladder cancer and are undergoing chemotherapy followed by radical cystectomy. Her project aims to study how personalized exercise intervention and pragmatic prehabilitation can improve patient outcomes and health related quality of life. Dr. Psutka, thanks for joining our podcast today and congratulations on your BCAN TCTA award.

Dr. Sarah Psutka:

Thank you so much, Rick. We are absolutely thrilled about the award and so excited for what it’s bring and I’m really excited to be here with you today.

Rick Bangs:

Our pleasure. So we typically start our podcast by defining the topic and I think that’s particularly important here. So can you start by defining the population of interest here? The term older adults doesn’t quite hit the mark, does it?

Dr. Sarah Psutka:

No, I think that’s a really astute observation, which is that when I think about the population of patients with bladder cancer being kind of overly simplistic and just saying it’s a disease that affects older individuals or it’s a disease that affects patients who look like this really is not true because bladder cancer can affect folks who are young. It can affect folks who are in their later decades, but also every single person is a little bit different. And so what I really worry about is patients sort of individual risk factors and everyone has their own individual risk profile. And so the work that we’ve been sort of driving forward really aims to understand every patient’s individual risk profile and then see how we can move the needle on that risk. And so it’s true that the vast majority of patients with bladder cancer are older. We know that the average age of diagnosis of bladder cancer is about 73.

However, one 73-year-old may have a totally different risk profile than another 73-year-old. And really age is just a number. What we think about is this concept of physiologic age. Also the concept of what’s called multimorbidity or sort of all of the other health issues that someone has to deal with while they’re also dealing with bladder cancer. So we talk about medical complexity, we talk about physical function and also the opposite of that, which is physical frailty or sort of physical vulnerability. And we really are trying to get at this concept of what is it biological age or physiologic age, it’s how old or how young someone is taking into account all of their own internal strengths and the things that make them more robust or more resilient and the things that they’re dealing with that may actually reduce their resilience or make them a little less likely to tolerate certain stressors. That’s kind of where we kind of hunker down around this conversation of personalized risk and resilience assessments.

Rick Bangs:

So personalization is really key here.

Dr. Sarah Psutka:

Absolutely.

Rick Bangs:

All right. And as we age, things do change with our bodies. That’s kind of the norm. So what happens as we age relative to cancer and bladder cancer?

Dr. Sarah Psutka:

We know that as we get older there’s an increased risk of diagnosis of all cancers, but certainly bladder cancer, the risk of being diagnosed with bladder cancer increases with age. The risk of certain types of cancers go up considerably with advanced age. And then other cancers are really more sort of genetically mediated. And in those cases we can actually diagnose those at a much higher rate in younger individuals. But there’s also changes as we all age, unfortunately, we also a lot of times collect other medical problems, kind of like what I was talking about before. So for example, the risk of heart disease, lung disease, vascular disease goes up as our bodies age and that’s a natural part of living longer. The environmental factors that we’ve been exposed to, the lifestyle factors that our bodies have been exposed to across the years can increase this.

What we certain times refer to as the burden of comorbidity, which is really the other list of medical issues that impact someone’s physical health wellbeing and then ultimately sometimes their risk for developing cancers as well as their risk of being able to tolerate the treatments of certain cancers. Then there’s other just natural things I think we think about testing results. So a good example of that sort of being different as patients age. There are also just aged-based changes in certain lab parameters. So for example, some of our listeners may be familiar with the idea of PSA testing, which is a blood test that’s used for prostate cancer testing. Naturally as men age baseline PSA just goes up. So the way that we interpret certain lab values has to change in an age specific fashion.

Rick Bangs:

Okay. So now let’s think more broadly about the aging of the US population. And people like me were part of something that was often referred to as the baby boom and there are certainly a lot of us and we are getting older, many of us are retired or we’re soon to be retired. So if we step back and look at it from a public health perspective, what are the implications of that?

Dr. Sarah Psutka:

Well, I think that this is a really important epidemiologic trend that we all need to be aware of. So as the United States population is aging, we have a lot more patients who are reaching this sort of these older decades. The other part of all this is actually people are living longer. I know there’s a lot in the news about the sort of drop in life expectancy in the United States. A lot of that has been related to the pandemic and a lot of other stressors that are acutely affecting certain parts of the population. But as we age, there is definitely a large number of patients or people who are living longer. And that means also there’s a lot of people who are going to be a larger proportion of people who are going to be at risk for these aging related diseases.

And so the prevalence of cancer is going to go way up in our older patient population because people are living longer. So there’s more time to potentially develop these cancers. The other big part of all that though is there’s actually not very many specialists who have the degree of expertise in the management of older individuals healthcare. There’s a supply and demand issue there. So the physicians who classically are the experts in taking care of older individuals or geriatricians, and that’s actually a fairly small part of the healthcare workforce. It’s an area that has definitely gotten a lot more interest and publicity within medicine in recent years. But I’ll tell you, even when I was in training, which doesn’t seem that long ago, but I guess maybe it is now, I don’t know that I remember a geriatrics lecture when I was going through medical school.

Now I am spending a lot of time and we did a couple months of pediatrics. You do a couple of months of OB-GYN and you do these different months of all of the surgery and medicine and infectious disease and radiology. But I never actually spent a month doing geriatric medicine, which honestly I kind of wish I had. I’ve spent a lot of time recently trying to teach myself and become really a lot more familiar with principles of geriatric medicine and geriatric oncology specifically because the vast majority of the patients I take care of do have a high burden of these kind of aging related medical concerns. But I think learning principles of geriatric medicine are really critical and we definitely need to expand that aspect of our workforce as doctors, the number of providers who are really comfortable and have appropriate expertise to care for this aging part of our population. ‘Cause that’s the one thing, as we all get older, we need more people who are able to take care of those folks.

Rick Bangs:

Right. And I remember Atul Gawande in that the book being mortal talking about this shortage and some of the specific issues and the way you want to make decisions as a family member whose got an older parent or a sibling or whatever.

Dr. Sarah Psutka:

I think that one aspect of medicine, which is really, I would say it’s kind of the art of medicine that we need to, I would think in medical education I would put forth that we need to spend a lot more time thinking about is this concept of shared decision making. And it becomes ever more important I think, across the aging cycle. And there’s a really great book that I just love called Elderhood that is a book that kind of comments on, we talk about childhood and adolescence and young adulthood and middle age and elderhood is kind of that latter phase of life, but what actually is a very oftentimes long and very rich part of life and how do we maximize the quality of life for patients as they’re in their elderhood and not having it be sort of a part of life that we kind of write off.

That’s actually oftentimes a very, to some degree it’s a complex time of life because there are often a lot of medical issues going on, but also that’s when some patients maybe they’re focusing on things that they really enjoy, maybe they’re not working anymore and they’re retired, maybe they’re spending a lot more time with family than they were able to do so when they were in their earlier years when they were really focused on financial stability. And then there’s a lot of issues around patients who don’t have a lot of financial stability in that time period and what sort of resources we need to generate to make sure that they are able to live well and independently.

But I think one, I love that book Being Mortal and I’m going to paraphrase here, but one of the quotes that I always take from it is this comment that Gawande makes where he says the job of, and I’m paraphrasing heavily here, but, “The role of a physician is really to help patients essentially live well,” but living well, what that means is very different for patients in different situations. And this whole, it kind of gets back to the concept of cancer survivorship for our patients with bladder cancer and other malignancies, which is that it’s not just getting to the finish line and ringing the bell and maybe being disease free. Some patients may not ever become disease free. We certainly know that from our non-muscle invasive bladder cancer patients where the bladder cancer almost becomes kind of a chronic illness, it’s all about having patients live as well as they possibly can and have as much quality of life as possible throughout the whole journey from diagnosis through any of the different types of treatments and then surveillance or ongoing treatment.

Rick Bangs:

What really struck me was the conversation about it was kind of around what do you want or what does the person want to get out of the rest of life out of the situation? And it was really powerfully done.

Dr. Sarah Psutka:

Yeah, there was a really important landmark study that was published in the early 2000s that looked at how older patients weight different outcomes sort of differently compared to younger patients. And I think it’s something that I do think about a fair amount where in the study it was a survey study where older individuals routinely and impressively over, or I guess let’s just put it this way, they prioritized quality of life much more heavily than length of life. So they would’ve much rather lived a shorter period of time, but had that been high quality time at home with their family living independently than perhaps living a longer period of time in a say a care facility or with substantial functional disability.

And I think that at this point, international guidelines mandate that when we talk to patients about their treatment options, a key part of that conversation is asking patients, “Well, what does a successful outcome look like to you?” And I lead a lot of my conversations with my patients about that, with that kind of sentence, which is really like at the end of the day, we look back at this and we say, “We did a good job and we gave you the best outcome we could have, what would that outcome be for you?” And for some patients, it’s living as long as possible and for other patients it’s living at home unassisted and being able to still drive. Or for some patients with bladder cancer, it’s keeping their native bladder and not having some sort of reconstruction. Other patients, it’s being pain free. So I think that understanding what patients prioritize is really, really important. And then the next part of all of that, of course, is we need to do a much better job of being able to predict what that person’s specific estimates of those outcomes look like.

Were pretty good in medicine at giving kind of percentages of 100 patients with this illness. Five-year cancer specific recurrence rates are X, but that’s across everybody. And it really doesn’t help the person who has maybe no smoking history, but a genetic predisposition to this type of cancer or the patient who was a firefighter and so has a higher risk of recurrences. Those gross sort of generalized numbers really don’t, I think help patients make decisions. What helps is when we can get really granular and give a patient a much more sort of clear idea, “Best case scenario, here’s what we can expect for you, worst case scenario, here’s what we can expect for you, here are the different sort of outcomes.” And then really focus on the ones though that are most salient for that person.

So we talk a lot about this being in the era of personalized medicine, and a lot of times that’s used to specifically talk about genetic risks and molecularly directed therapies, but I actually think of it as in a much broader context where we really need to be thinking about the whole person in front of us and that that’s not only biologic, it’s sociologic, it’s kind of ecologic, it’s the support network, it’s the finances of the disease and how that’s going to impact their quality of life. It’s kind of all of these things. So that’s where I feel like I’ve been spending a lot of my time reading about how to do a better job of being a bit more of a holistic provider with respect to that counseling piece of this.

Rick Bangs:

Yeah, I love the application of the holistic and the intersection between holistic and personalized medicine. I think that’s so correct. So let’s talk a little bit about aging and bladder cancer specifically. So what are some of the things that you and your patients might specifically consider and discuss relative to treatments for patients who might be older bladder cancer patients who might be older or they have aging related concerns and medical complexities?

Dr. Sarah Psutka:

Well, I think it’s a really kind of complex topic, but the truth of the matter is baseline physical fitness and burden of comorbidity can very strongly impact what treatments are available to certain patients. And I think that this is actually a really complex topic, and it’s something that I’ve spent a lot of time in the last 5 to 10 years kind of trying to study. So we know that patients who have higher burdens of comorbidities are going to be more at risk for tough outcomes after some of the treatments for bladder cancer. So for example, after radical cystectomy or after chemotherapy or some of the systemic medications that we use for advanced disease, but even for the intravesical therapies, having additional complexity at baseline can impact complication risks as an adverse event risks. If patients, for example, don’t have good kidney function at baseline, that affects whether or not they can actually even receive the kind of key chemotherapeutic that we think is really important in bladder cancer, which are platinum-based chemotherapies or cisplatin.

Rick Bangs:

Yeah, we did a whole podcast with Guru Sonpavde who I’m sure you know.

Dr. Sarah Psutka:

Sure.

Rick Bangs:

Just that topic, I Can’t Get Chemotherapy to Treat My Bladder Cancer – Now What? So for our listeners, episode 15 is a reference point here.

Dr. Sarah Psutka:

And it’s absolutely critical. There’s also, one thing that I think about a lot is we base our care decisions on, for the most part, randomized clinical trials, which are basically scientific experiments where one treatment option has been pitted against what was previously the standard of care with the goal of advancing options and having better treatments available for our patients. But what’s really important is that the folks who can get into those trials oftentimes don’t really look like the patients, the general population with that disease profile, because the people who get into those trials are usually the folks who are otherwise a little bit less complicated, maybe have a lower burden of disease, they might be younger, there may be age cutoffs, there may be, there are oftentimes cutoffs in terms of organ function, kidney function, liver function, heart cardiac function where there’s what they’re called to exclusion criteria where if a patient has a history of a heart attack, well that may preclude them from even entering the trial.

But then of course the trial sort of generates the level one evidence or the highest level of evidence that then guides guideline-based care. But if the vast majority of the patients with the disease process could never have gotten into that trial, then we don’t really know how that treatment option behaves in the general population. It’s this concept in science of generalizability or external validity. What’s really tough is that a lot of our older patients and our patients with aging related health concerns are sort of systematically excluded from clinical trials because most of the times with trials, you’re trying to get a new drug or a new agent or a new treatment to the front of the line. And when you have a more complex patient population that introduces potentially more noise and might threaten the success of that treatment intervention that you’re testing, you stack the cards in the favor of the drugs that are being tested.

And that’s part of you’re trying to test a new drug in the, “Cleanest,” or most sort of controlled setting, but of course with the real world is not heavily controlled. And we all have things that make us different. And that’s where one of the tricky bits comes in where a lot of times patients may not be eligible for a lot of the treatments that are considered guideline-based care. And that’s especially true for patients who are older or who have aging related health concerns. I see a lot of patients in my practice who are octogenarians or nonagenarian with newly diagnosed bladder cancer. And so we have a lot of conversations, tough conversations around whether or not they can get cisplatin-based chemotherapy and a lot of times they can’t or whether or not they can go forward with something like a radical cystectomy. And then that’s where these kind of discussions around trade-offs and risk benefit ratios really become super important.

And also we spend a lot of time thinking about, “Okay, well, so we need to do a much better job of getting to know those patients.” And that’s where the idea of a geriatric assessment comes in, which is a really comprehensive evaluation of a patient’s personalized risk profile that actually puts numbers on a lot of the things that we’ve been talking about. So it’s not just a gestalt impression that, yes, this patient can get treatment, I think I can get them through this treatment safely. It’s a really detailed assessment of frailty measures, physical function, mental health, cognitive function, comorbidity burden, and how it actually impacts a patient’s day-to-day living, ’cause that’s really important. If you just have a diagnosis of hypertension, but you take one pill a day and it doesn’t really affect your life, that’s one thing. If you have severe hypertension, you have to take three pills a day and you’re still not able to control your blood pressure. That’s a totally different, totally different issue. Or diabetes and insulin use and things like that.

So those are some of the things that we talk about. What are different options that we can really safely offer patients? And then some patients are more willing to accept certain risks if it means a greater chance of achieving the outcome that means something that’s really meaningful to them. And other patients prioritizing quality of life and independence and staying out of the hospital and not being potentially subjected to really potentially problematic outcomes like complications or adverse events. They may prioritize that and say, “I’d rather not take the less intensive treatment option here and just focus on being able to live my life the way that I’m living it right now for as long as possible.”

Rick Bangs:

So I’m curious what happens as we age relative to how cancer treatments work?

Dr. Sarah Psutka:

I think about this a lot because I have two young kids and they’re basically little stem cells. They fall and bunk their knee or get a scrape, and by the time I’ve gotten them back to the house to put a BAND-AID on it’s already healed. Little kids and young adults and young humans heal incredibly quickly. As we age, we take longer to heal. So what does that mean? It means that while a 55-year-old going through a radical cystectomy might be out of the hospital in four to five days or even shorter and be kind of back to their physical baseline by say six weeks after surgery, an older patient, like some of my octogenarians, it might be more like six to nine months before they kind of feel like they’re at their baseline again. And it’s important I think, to set appropriate expectations in terms of what recovery really looks like and when patients may feel like their appetite is back or their endurance in terms of being able to walk to get the mail or do their grocery shopping by themselves.

So that’s definitely a sort of an important factor. Some patients, like we’ve already talked about, as we age, may have other medical issues that make it hard for them to get certain treatments. So for example, kidney function tends to decrease with age because as we age, we’re more likely to become more hypertensive. There’s a risk of higher risk of in certain patient populations get developing diabetes that can affect kidney function. We may have been exposed to more kidney toxins, so that can affect kidney function so that that’s where the cisplatin may not be as that might a less of a viable treatment option. Another thing is cisplatin is classically, and I’m sure you talked about this in your other podcast, it’s associated with increased risk of developing neuropathy. So nerve damage. And that can affect things like hearing can affect things like the feeling in your fingers and your toes and peripheral neuropathy, which can affect patients’ ability to walk and do the things that they need to do every day.

So again, those kind of more intense treatments may sort of be off the table because we don’t think a patient can safely tolerate the drug. And then of course, one of the really exciting things that’s happened in the last few years is that we’ve got this whole new class of drugs that are available to us in the management of bladder cancer, which is really exciting. And these are immune therapies or immuno-oncology therapies. The way I explain them to patients is these drugs which work a couple of different ways, but really generally they kind of take the breaks off the immune system. So cancer’s really smart in that it can kind of hide itself from the immune system that normally would be looking for cells that are not supposed to be around. So our immune system is constantly surveilling our body for bacteria and viruses.

It’s also looking at cells that have kind of gone bad, which is really what cancer cells are, but cancer cells can sometimes sort of hide from that surveillance. And when we use these immuno-oncology-based drugs, these checkpoint inhibitors, we kind of let the immune system just be almost kind of weaponize it to fight the cancer. The issue is some older patients may have the risk of what are called immune related adverse events or the sort of immune side effects. They can be much stronger. And so there can be a higher risk, for example, of the really severe sort of overactivation of the immune system. So inflammation basically that’s so bad it’s not tolerable and we have to stop the drug or we have to use steroids to quell the immune system. There’s also a higher risk of immune related death, which doesn’t happen very often. It’s 0.3% to 1% of patients on those drugs, but that risk seems to be a little bit higher in older individuals.

Rick Bangs:

You talked about clinical trial eligibility and it’s important to have generalizability and I think sometimes, I mean, think it’s important that people recognize that race and ethnicity are a part of that, but so is age, and it seems like there’s been a lot of work in the last several years to try to recognize these eligibility considerations on how they are halting or hindering this generalizability concept. And I think age falls into that category at least that’s my observation.

Dr. Sarah Psutka:

Oh, I couldn’t agree with you more. It’s actually something that when I have the opportunity to speak with our sponsors from industry who are running these really important trials and testing these brand-new agents that could have the ability to potentially change the face of how these diseases progress. I try to make the point that sort of gross cutoffs a lot of times one, are problematic because we’ve already talked about age is just a number. It’s just like BMI is just a number. You can have a BMI of 33 and be a world-class athlete. A BMI body mass index just for our listeners is just one’s weight divided by one’s height that’s been squared. And it’s a classic way of assigning categories of obesity. But the point is you can technically be obese just by weight, but actually be incredibly physically fit and just very muscular because muscle weights more than fat.

Well, age is the same. You can be 65 and be a world-class marathon runner, you can be 65 and require an assistive device because of mobility issues because of really advanced diabetes or heart disease or lung disease or any kind of other things or cancer. So I think that using these kind of gross cutoffs is really problematic. What we need to do are much more kind of data-driven assessments of physical fitness and physical function, or the opposite, which is physical frailty. And that’s where assessments like geriatric assessments can be really helpful because we can get a much more kind of clear understanding of someone’s own sort of risk versus resilience profile. But you’re right that the problem is if patients that are older or who have specific risk profiles are systematically excluded from clinical trials, well then we don’t really know how the drugs work in those patients.

And then in the real world, we get into trouble because we don’t extrapolating data from these really tightly controlled trials, scientific experiments to patients who never would’ve made those inclusion and exclusion criteria. And then that becomes… Occasionally we can actually see paradoxical results. So it’s really important, I think that we try to be as best we can be as safely as we can be to try to be a little bit more inclusive and pragmatic when we think about clinical trial design, or one of my partners, Dr. John Gore is running with Dr. Angie Smith, is running an incredible study called the CISTO Study, which is looking at what are the different implications of treatment options for BCG non-responsive, non-muscle invasive bladder cancer is advanced non-muscle invasive bladder cancer. And looking at patients who take other treatment options to preserve their bladder versus patients who go ahead with radical cystectomy.

You can’t do a randomized controlled trial where you randomize patients to a surgery like radical cystectomy versus other medical options; that’s unethical, but through really clever analytic methodology. They can try to get at an answer that will provide patients with much more information to help them make that decision making. And I think that we are moving into the era of being a little bit more thoughtful about designing trials that maybe are still are ethical, but actually give us more information about patient populations outside of these traditionally sort of very healthy groups who qualify for clinical trial and enrollment, who are also usually quite a bit younger.

Rick Bangs:

Some great work there. And Doctors Gore and Smith are well known to the BCAN team and the BCAN community. So things to watch there.

Dr. Sarah Psutka:

Absolutely.

Rick Bangs:

What about things that aren’t biochemical? What might some of those considerations be for this population?

Dr. Sarah Psutka:

Well, bladder cancer is the most expensive cancer that we take care of in the country. And the reason for that is that the management of bladder cancer is very procedure heavy in the non-muscle invasive space. It’s a lot of cystoscopies and biopsies and resections and then all of these medicines that we put into the bladder six weeks at a time of induction treatment and the radical cystectomy is a big deal. The chemotherapy is a big deal, and then the surveillance afterwards is a big deal. So it’s in terms of what we call financial toxicity or the amount of expense that patients incur, it’s a huge deal. Logistically, it’s a huge deal. It’s hard for patients to maintain their, if they’re working to be able to keep working as they’re going through all this therapy, it’s also hard for maybe their care providers who are providing them with a lot of the transportation to not have considerable impact on their financial viability and their ability to maintain their employment.

We also take care of a lot of cancer care in the country as being centralized to high volume cancer centers and tertiary and quaternary care centers. That means that a lot of patients who might not live close to those big centers, which are oftentimes in big cities, may not have as many opportunities for care and they have to travel really far. And that’s both expensive and logistically challenging, especially if folks don’t have social support to drive them. I take care of a lot of people being in Seattle who come down to see us from Alaska for their surgery or come from any of the WWAMI states, the Washington, Wyoming, Idaho, Montana, and Alaska. All those different states they’re in our catchment area. So some of my patients come six to eight hours for even a cystoscopy, not just the big surgery, but even their routine every three-month cystoscopies.

So it’s a huge, huge deal, and I think that you can’t underestimate the importance of social support and the treatment burden not only on the patient, but also on the caregivers. And that’s where we really need to do a better job I would say, and this is perhaps a little bit of a political statement, but I think it’s an important statement. We need to support our patients, which means try to improve access to care and also think about ways that we can thoughtfully decrease the cost of care so it can be more available and there aren’t disparities based on ability to access care.

Rick Bangs:

We need to better balance that equation.

Dr. Sarah Psutka:

100%.

Rick Bangs:

So as we seek improvement in bladder cancer healthcare for older adults and those who have aging related concerns and medical complexities, what should we expect from the clinicians? What needs to be done there?

Dr. Sarah Psutka:

Well, I think that a big part of it is we all need to train ourselves to continue to do a better job of risk stratification. So understanding a patient’s personalized risks. The problem is if we don’t do a good job of risk stratification and we don’t really understand a patient’s potential risks of tough outcomes with certain treatments, is that there’s a high risk of just grossly undertreating some patients and also over-treating other patients. So subjecting some patients to sort of an assessment that they’re not candidates for the treatment that they really do need, and then basically having us not control their disease appropriately. There’s other patients who we might be systematically overtreating where we’re subjecting them to a lot of excess risk potentially without that much benefit. So the way that we fix that problem is we do a much more careful assessment of each patient to understand their kind of unique balances of risks and resilience.

I think that there’s also ways that we can move the needle on a lot of those risks. So part of it is really thinking, we talk a lot about multidisciplinary cancer care, and I think that multidisciplinary cancer care is typically thought to mean sort of our cancer team working really closely, including our medical oncologists and our radiation oncologists and urology, our urologic oncologists. And we do. We’ve now, we really rely on each other and I think we work really well as a team. But that team is a lot bigger than just those three specialties. That team involves anesthesiologists who are especially well-versed in taking care of medically complex patients. It includes physical therapy and occupational therapy, pelvic floor, physical therapy. It includes social work, it includes nutrition, it includes… I work closely with our physical medicine rehab specialists because there’s a lot of work that can be done outside of the standard cancer appointments to maybe really work on controlling someone’s heart disease better so that they can get the cancer treatment that they need.

Or maybe it’s if a patient is struggling to, if they really are malnourished at baseline or they have mental health concerns, we actually have a really wonderful cancer psychiatry and psychology program at the Fred Hutch Cancer Center that I rely really closely on to help us help our patients cope with their diagnosis so that they can get the treatment that we are trying to deliver. Our physical medicine and rehab docs do an amazing job of developing these personalized exercise prescriptions that are not just going to a gym and doing a bench press or running on a treadmill, but they’re really thinking about, “Okay, somebody’s going to go through abdominal surgery. So if that’s the case, we need to be able to get that patient out of bed and moving on day one, we need to think about how we can ensure they’re not a major fall risk during their initial recovery.”

So we talk a lot about balance and core strength and creating safe spaces at home where people can transfer really easily. Maybe sometimes it means moving a bed or getting some additional assistance equipment into the home that allow people to shower safely after surgery. There’s just so much we have to take a big step back and think, “Okay, but how do we make this whole process easier for somebody?” And with a bit of a bent looking towards these aging related concerns. So I think that it’s a complex answer to a very complex question, but really I think that what it ultimately means though is we don’t have to reinvent the wheel. I don’t need to become a physical medicine and rehab specialist, but I can become really good friends with my [inaudible 00:37:03] and our colleagues.

Rick Bangs:

Right. Right.

Dr. Sarah Psutka:

And I think that’s where it all comes down to building these really deep teams that we can rely on. That’s ultimately it. It’s making sure, I think that we really work well across our different specialties to give patients this really comprehensive care package as opposed to just working in our silos.

Rick Bangs:

Right. So now if we flip it to the patient side, so what should they do to improve their healthcare?

Dr. Sarah Psutka:

The biggest thing I hope that my patients always know with me is that they can just tell me what really matters to them. And so my job is to understand what they care about most. And so I think from the patient side, it is being an advocate for oneself or if you’re a family member, being an advocate for your family member and not being afraid to ask tough questions and not being afraid to sort of voice what really matters for them. And if you’re not, sometimes it’s hard to do sometimes in the context of these really quick visits, we’re only given say 10 to 15 minutes for a return visit, or I think at the end of the day though, at least in my world, we definitely try to take the time to really understand what patients care about. And for a patient, you should never be afraid to speak up, ask a question if you don’t understand something or say, “No, this is what really matters to me.”

I do tell patients also, I think it’s tricky. A lot of times when patients are coming in for new consultations, they may not have really thought about what matters to them because that’s kind of the truth in the current society. There sometimes can be some shame or I would say lack of comfort saying, “I really want to prioritize me, or I really want to prioritize my independence.” And I tell patients, “There’s no right answer. What looks like a successful outcome can be very different for one 86-year-old with bladder cancer compared to another 86-year-old with bladder cancer or one 50-year-old with bladder cancer compared to another 50-year-old with bladder cancer. So I think I try to give patients the time and the space to say, “I want you to talk to your family about what really matters to you, and then tell me about it.” I don’t expect them to know those answers in the first visit. That’s why I think a lot of times, like treatment decision making takes a couple of visits to kind of get it to what really matters.

Rick Bangs:

And it may vary across time too.

Dr. Sarah Psutka:

Absolutely. And that’s okay too. And it can change. Sometimes people make a decision and then they come back a couple minutes later and they say, “No, you know what, this matters now,” and that’s okay.

Rick Bangs:

Exactly. Okay. Any final thoughts on this topic?

Dr. Sarah Psutka:

No, I really appreciate the opportunity to chat about this. These are things I certainly think about a lot. I definitely am always trying to learn about. To some degree medicine gets a little bit reductive at times where we try to put people into different buckets based on problems that they might have or diseases. And I think we really have to remember the richness of each individual and spend some time. It comes down to getting to know our patients and getting to know what matters to them. And I just hope that patients feel that they can always speak up about what matters most, especially when they’re making big decisions about how to treat bladder cancer, how to give themselves the best possible outcome.

Rick Bangs:

Absolutely. So Dr. Psutka, it’s been a pleasure to talk to you and I want to thank you for helping us understand that both the challenges and the opportunities that patients may have who are older and have aging related concerns and medical complexities, and how they can best manage the associated risks and benefits. If you’d like more information on bladder cancer, please visit the BCAN website, www.bcan.org. In case people would like to get in touch with you. Could you share your Twitter handle or any other information you would like people to have?

Dr. Sarah Psutka:

Absolutely. So my Twitter handle is @spsutkamd, which is just my first initial and last name. Always excited to hear from people about sort of what’s working for them and challenges they’re facing. So thanks for the opportunity to speak with you today.

Rick Bangs:

Okay, great. 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. If you liked this podcast, never miss an episode by clicking on the subscribe button on your favorite podcasting platform and rating our podcast helps us reach more people. Please feel free to leave a review as well. Thank you for listening, and we’ll be back soon with another interesting episode of Bladder Cancer Matters. Thanks again Dr. Psutka, and good luck on the Get Moving Trial.

Dr. Sarah Psutka:

Thank you so much, Rick. Talk to you soon.

Speaker 1:

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, advanced 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.