Transcript of The Advantages of Shared Decision Making in Bladder Cancer Care with Dr. Aditya Bagrodia

March 18, 2024

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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.

I’m pleased to welcome today’s guest, Dr. Dr. Aditya Bagrodia. Dr.Bagrodia is a urologist specializing in genital urinary cancer, including bladder cancer. He completed fellowships at Memorial Sloan Kettering Cancer Center in New York City and UT Southwestern Medical Center in Dallas. He is currently Associate Professor in the Department of Urology, UC San Diego School of Medicine, where he leads the genital urinary disease team.

He is dedicated to guiding his patients on a path that is best for them, both in terms of survival and quality of life, including navigating the latest treatments. Whatever the particular condition and the ultimate treatment plan, he believes that a collaborative approach to care is essential.

He’s the principal, author or co-author of more than 150 articles and peer reviewed publications. He is also a reviewer for many of these publications, and in addition, has contributed to several textbooks and hosts the BackTable Urology podcast. In his free time, Dr. Bagrodia enjoys traveling, soccer, running, tennis, squash, table tennis, cooking, and spending time outdoors with his family.

Today’s podcast will be a first for us, because Dr. Bagrodia is one of the hosts of the popular BackTable Urology podcast. The BackTable Urology podcast is for practicing urologists and listeners, to learn how leading physicians tackle major urological conditions, with medical and surgical approaches. As Dr. Bagrodia is our guest today, for the first time, we plan to publish this podcast in conjunction with Backtable Urology. So this podcast will be available and published in two places, and we are really excited about that.

Dr. Bagrodia, thanks for joining our podcast.

Dr. Aditya Bagrodia:

Rick, it’s an absolute honor. I’m so thrilled to be on it. I am a huge fan of the BCAN podcast series. They’re just tremendous. I’ve heard yourself and other patient advocates speak in a couple of different forums, and again, just honored to be on the podcast.

Rick Bangs:

And we’re thrilled to have you as well. So I want to start by defining this very important patient goal called shared decision-making. Can you tell us, what is that and how will we know if we’ve achieved it?

Dr. Aditya Bagrodia:

Sure. Sure. So maybe before I just jump into it, I think it’s worth sharing, from the physician perspective, when we make a decision, and just like any human, we’re making hundreds if not thousands of decisions every day as it pertains to patients in our everyday lives, when we make a decision, there’s not a neon light that pops on that says, you got that decision right, or you got that decision wrong. And it becomes even more challenging, so there could be lack of data surrounding any given decision, and then it’s also more challenging, because of course, we have to make sure that we have incorporated what the patient sees as right or wrong. The patients are our true north, so what we may think is the best for any given patient, based on available data, that may not be best for the patient.

So that’s where, I think, shared decision-making really comes into play. And we’re fortunate, as urologist, there is a lot of gray where there’s not a clear cut you should or you shouldn’t do this. So we actually have some definitions. And really, what shared decision-making boils down to, it’s a collaborative approach to care that improves the quality of medical decisions, by helping patients choose the options that are best in line, best concordant with their values, and the best available scientific evidence merged.

Rick Bangs:

Okay. So what would some of the advantages or outcomes be, if we achieve this goal? And are there any disadvantages?

Dr. Aditya Bagrodia:

Yeah, yeah. So a obvious advantage is that, certainly, if there’s options that exist or a couple of different management strategies, patients that have engaged in shared decision-making, they have more knowledge and decision satisfaction. And generally, we see less decisional regret. So the more we can educate our patients about some of the options that are out there, the more informed, the more empowered they feel to make the best decision for themselves, so they can go on and feel comfortable, however things play out.

I mean, a obvious example for higher risk muscle invasive bladder cancer would be, do you want to undergo chemo radiation or cystectomy without chemotherapy, a neobladder? Now you could come into my office and I could tell you what I think is the best option. That may or may not be the best option for you. Your goals and hopes and desires and priorities are front and center, when there’s not one clear cut option based on best available evidence. So that’s kind of an example, if that’s helpful at all.

Rick Bangs:

Okay. And do you see any disadvantages?

Dr. Aditya Bagrodia:

Yeah, yeah. I think, when there is clear cut evidence, it could be an opportunity to shift away from evidence-based medicine, that’s not good. In the acute care setting, if you come in with a heart attack, that may not be the best time to engage in shared decision-making, where the best decision may be to get you to the cath lab and sort things out. So the acute care setting can be a little bit challenging.

I don’t want this to come across as being a little suspicious, but you could imagine where shared decision-making kind of becomes a catchall to do whatever you want to do, as opposed to practice evidence-based medicine. So I actually think that having shared decision-making as a part of the evidence-based curricula guidelines is preferable.

Rick Bangs:

Okay. And so, with the exception of these kind of critical care kind of situations, why isn’t shared decision-making universal?

Dr. Aditya Bagrodia:

Well, there are scenarios where there’s high level data that a certain algorithm should be employed. I’ll give you an example. So I take care of quite a few patients with testicular cancer. There’s no stage four testicular cancer because we have highly effective chemotherapy. So if a young man comes in, between ages of 20 and 40, and they have metastatic testicular cancer, the standard is chemotherapy. It’s not super fun, but patients do great, and it’s curative. So in that context, and this is oversimplifying a bit, there’s not a ton of room for shared decision-making. It’s like, you need chemotherapy.

For bladder cancer, if you have gross hematuria, and a CT scan shows a large mass, suspicious for a bladder cancer in the bladder, the next step is going to be a cystoscopy with transurethral sectional bladder tumor and staging. That is a fairly clear cut guideline. And there may be some minor things that we can kind of implement in there. Do you want to do an office cystoscopy before the OR? There could be some fairly small pros and cons of that. But basically, you need a transurethral sectional bladder tumor. So again, not tons of shared decision-making options in that context, in my opinion.

Rick Bangs:

Okay.

Dr. Aditya Bagrodia:

Does that make sense? Does that help?

Rick Bangs:

No, that makes perfect sense to me. Perfect sense.

So as a patient, what role can I play to ensure that I end up with shared decision-making?

Dr. Aditya Bagrodia:

And it might be helpful to kind walk through various disease states, from low grade non-muscle invasive, to intermediate risk, non-muscle invasive, and so on across the way. I mean, the first thing is education, to educate yourself. BCAN is a tremendous organization, which really, again, empowers patients. And I’m not just saying that lip service, and perhaps, I’ll give an example from my life on where I think I could be told what to do or I could engage in shared decision-making.

So I spend my time being a urologic oncologist, thinking about taking the best care of patient with urologic cancers. Twice a year, I get on the phone with somebody at Fidelity, and we talk about my personal finances. And this is not an excuse, but the extent of that is, what would you do if I was your brother? And a few years, it’ll be, what would you do if I was your dad? And that’s my kind of due diligence, and it’s a crazy thing. This is an important part of my life that’s going to impact my financial health. And I wouldn’t say that I’m overly educated on it.

Now, if I came in and I could say, “Hey, how do you compare and contrast investment strategies X, Y and Z?”, maybe the person would say, “Well, we are currently on a certain type of plan, but it’s interesting that you brought that up. Perhaps this type of plan is better for you.” So for a patient, I think understanding what options are available, not feeling shy or embarrassed or ignorant to ask and advocate for their own care is critical. And again, just recognizing that there’s not always a single best option for any given patient, or data to suggest you should do one thing or not do another thing.

Rick Bangs:

Right. So it sounds like kind of the fundamentals, listen, ask, learn. Those are kind of fundamental to this thing called shared decision-making.

Dr. Aditya Bagrodia:

You got it.

Rick Bangs:

All right. So what challenges might patients run into, or their caregivers?

Dr. Aditya Bagrodia:

Well, I think when you go in, particularly as a new diagnosis, cancer diagnosis, you’re scared, and you’re going to trust that the person advising you is going to have knowledge that you don’t have, and that knowledge that’s going to be shared is going to be the best for you.

Rick Bangs:

All right.

Dr. Aditya Bagrodia:

And I think that’s actually a reasonable assumption, that doctors are trying to help you. To question some of the recommendations may be a little bit tough. This is somebody that’s going to be ultimately responsible for your care, navigating a cancer journey. You don’t want to come across as being confrontational, as upsetting the team that’s going to be managing you. I think, understanding all the information too. If the first time that you’ve heard you have cancer is in the 15-minute follow up setting, and your mind is probably going a gazillion miles an hour, all you want to do is not die, and now you’re making decisions on chemo radiation versus neoadjuvant chemo, plus or minus neobladder conduit, pouch. I mean, that’s absurd. You don’t even know what to ask. And I think that’s a big part of it, is not even know what to ask.

And in general, I do think that taking a deep breath, slowing down a bit, and being deliberate on making a decision before jumping into a decision that you can’t undecide is almost always the better part of valor. And most, in my opinion, excellent physicians, excellent systems are going to make that part and parcel of it. For instance, if you’re a newly diagnosed, most invasive bladder cancer patient at UC San Diego, you will meet a multidisciplinary team, including urologic oncologists, medical oncologists, radiation oncologists, who will run through all your stuff, and present all viable options. And it may be, everybody feels that option A is best. It may be, here’s options A, B, C, D and E. Why don’t you think about which one’s best for you, and we’ll help you to know that you’ve got options? There’s no one best option, but we want you to pick the one that’s best for you, incorporating your values and beliefs and hopes and desires.

Rick Bangs:

Yeah. And I think the inclusion of the multidisciplinary team can be really helpful in this context.

Dr. Aditya Bagrodia:

Second opinions. I’m a full supporter of second opinions. I think any good doc will say, “This is well within your right, and here’s a couple of people that I know and trust, both within and outside of the institution.” I try to do that as well.

Rick Bangs:

Yeah. We’ve talked about this before on the podcast, and getting second opinions is often very important. One of the recent podcasts we talked about, not necessarily collecting a portfolio of second opinions to have a portfolio, but just to validate. And the good doctors tend to be very comfortable with you getting the second opinion.

So what are the challenges on the side of the medical team?

Dr. Aditya Bagrodia:

I think sometimes we feel like we know what’s best, and it’s not paternalistic in a narcissistic way. So for instance, if you’re a 45-year-old with a bladder chock full of muscle invasive bladder cancer, without kind of getting into the nitty gritty and the disclaimers that I haven’t seen the patient, my general reflex is, “Let’s be aggressive. You’ve got lots of life here ahead of you. Let’s keep you around. Maybe you have a family. And let’s start out with chemotherapy, followed by cystectomy, prostatectomy, lymphadenectomy, urinary diversion. We want to be aggressive, from a cancer perspective, we want to keep you around.” That’s nearly certainly how I would approach a 45-year-old patient with high risk muscle invasive bladder cancer. And I actually do think that’s the best thing for that patient.

Somebody else may feel, “You’re 45 years old. You got diagnosed with an aggressive cancer. The functional impact of cystectomy may be too much. Let’s start out with a chemo radiation approach and see how that goes. If it works, awesome. You get to keep your bladder, no impact on urinary function, sexual function. High fives all around.” So when I see that patient, I absolutely have some biases. I can’t get rid of them. And I would tell the patient, “Listen, John, you’re a young dude. You’ve got 16-year-old kids. We want to be aggressive, and the most aggressive option is chemotherapy, bladder removal.” And that patient’s priorities, or somebody else’s priorities, may be different.

Now again, in our setting, they would see everybody, and probably they would hear it from multiple different perspectives that chemotherapy followed by cystectomy is better. But we’re all coming in with our biases of what we think is best, ostensibly based on best available data. And it’s hard to get away from that. I think there’s some generational challenges. I think the more contemporary education does prioritize shared decision-making, whereas once upon a time, when there weren’t alternative options or effective alternative options, it was like, “Here’s what you got to do,” and it’s hard to get away from that.

Rick Bangs:

And certainly, the landscape is changing in terms of the treatment options. Bladder preservation is by far more commonly proposed, not to say it’s universally proposed or applicable, but it’s getting more momentum, because the landscape is changing, because there’s more evidence and data and options in terms of agents and so forth.

Dr. Aditya Bagrodia:

That’s right. That’s right.

Rick Bangs:

You talked about the multidisciplinary team, but I want to be kind of comprehensive. Who’s participating in shared decision-making on both the patient side and the clinician side?

Dr. Aditya Bagrodia:

Yeah. And you could say that the ultimate kind of key stakeholders are the patients and their caregivers. We want to provide all options, all evidence-based options, make sure that the patients and their caregivers have a comprehensive understanding of what those options are, what they look like, pros and cons, so that they could make the best decision for themselves. So the multidisciplinary team, you could say, is kind of the health side of it, which is, at best, 50%. The other half of it is going to be the patients and their caregivers.

Rick Bangs:

Yeah, and certainly, the caregivers can be incredibly important in terms of guiding the decisions. So engaging them, I think, can be extremely helpful.

Talk a little bit about tumor boards and how they play into this.

Dr. Aditya Bagrodia:

Yeah. So honestly, it’s getting another set of eyes, particularly for the less common cases. And essentially, tumor boards are meetings where cases, it can be common cases or can be complex cases, are discussed. And generally, it’s going to be, at the minimum, three types of medical doctors, a urologic oncologist, a medical oncologist, a radiation oncologist. Then there’s going to be several diagnostic doctors, a radiologist and a pathologist. And you want to review all the elements in detail. You can have other folks involved, social workers, nutritionists, a whole gamut of people, but you could say that, probably those five MDs are the core of any tumor board. And then geneticists, molecular pathologists, it can kind of continue to expand and those are wonderful.

But you’re looking at this through multiple different lenses, and generally, there’s several people kind of from each field. So for our tumor boards, there’ll be two or three urologic cancer surgeons. There’ll be two or three urologic medical oncologists, two or three urologic radiation oncologists, that’ll say, sometimes you can consider doing this, or here’s data supporting that. So it just gives you multiple lenses to look at any given patient scenario.

And then the tumor board, the multidisciplinary cancer clinic is when a patient comes in, and in the same setting, they’re going to meet with the medical oncologist, a radiation oncologist, a urological oncologist, either sequentially or together. So when they leave that, ostensibly, they have a comprehensive understanding of all the options that are available to them.

So in your case, rewind to 2006, which is crazy to think, 18 years ago, when you would’ve come in to see one of us, presumably with muscle invasive bladder cancer, you would’ve met myself, a medical oncology partner, a radiation oncology partner, to run through chemotherapy, pros and cons, surgery, pros and cons, urinary diversion, pros and cons, chemoradiation. Is this going to be radiosensitizing chemotherapy or systemic chemotherapy? And then, either you go home and our care never getters would help you understand what additional tests we may want and then arrange follow-up, or you would say, “Okay. Thank you all for meeting with me, after reviewing my options, I really think that cystectomy plus or minus chemo with neobladder is the way I want to go,” and then we’re moving.

Rick Bangs:

Yeah. You’re describing a much better situation than people would’ve seen in 2006. Much more collaborative, much more engaging on the multidisciplinary side, which is, I think, a huge benefit. So thank goodness we’ve made this kind of progress.

So I wanted to go through some goals for very common bladder cancer diagnoses, recognizing that there always are going to be some nuances, but just kind of get a flavor for appropriate goals for these most common bladder cancer diagnoses. So I thought we’d start with non-muscle invasive bladder cancer. We’re going to exclude, for a moment, the stage one or T1 high grade and patients with CIS. So what are appropriate goals for that non-muscle invasive bladder cancer patient?

Dr. Aditya Bagrodia:

I mean, I think, even just to substratify a bit for low risk, low grade tumors, the likelihood of these posing any type of threat to one’s life is thankfully exceedingly small. But we don’t want to happen for these to recur. Recurrences, not dangerous, but they’re inconvenient trips to the OR, multiple TURBTs. None of that’s fun. So the main goal, I think, for low risk is to prevent recurrences, and also manage the burden of surveillance, which comes along with bladder cancer care.

So this is, you could say, a good shared decision-making example in low risk. You come in with a solitary tumor, less than three centimeters. You get TURBT. It’s all low grade, mostly involved. Everything’s good. Maybe your doctor put in some postoperative gemcitabine or mitomycin. You’re coming in and the doc says, “Hey, Rick, pathology is good. Nothing dangerous here. We do have to monitor you.” “Okay, doc, what does that monitoring look like?” Well, person, urologist A, may say, “We’re going to look into your bladder at three months, six months, nine months, 12 months, and then six months for years 3 through 5. And then after that, every couple of years or so.” Urologist Dr. B may say, “We’re going to look into your bladder at three months, and then at a year, and then you’re going to give me a call if you ever develop blood in the urine.”

Now, those are very different surveillance strategies. The likelihood of the patient not doing well is, again, very, very small, but a certain person may like to have, and these are both kind of guideline-based surveillance strategies, more or less. Person A may say, “Doc, the cystoscopy is the worst thing that ever happened to me. I’ll take the two and I’ll give you a call.” Person B may say, “My whole family’s wellbeing hinges on these cystoscopies, and it just allows me to start the next three months feeling good.” I don’t have the monopoly on what’s the best thing to do. I can’t tell you if we watch every X or Y surveillance pattern, you’re going to do better or worse. Nearly certainly, it’s not going to change anything, but this is where the patient’s values and desires, I think, kind of come in a bit.

Rick Bangs:

Okay. That makes sense. And now, let’s go through the non-muscle invasive bladder cancer patient, who has a stage one T1 high grade and/or CIS. Now, this is a little riskier situation.

Dr. Aditya Bagrodia:

Yeah. I think the two goals here, very broadly, are not having you develop metastatic bladder cancer, progress and die of bladder cancer, not having your bladder cancer progress to where more intensive therapy would be required, that could be more life altering. And those are going to be the big ones. And then, of course, recurrence. We still don’t want these coming back, because even if they are, they’re still inconvenient. So there’s cancer control. There’s quality of life/bladder preservation, and then there’s recurrence, I think, are the overarching themes with high risk non-muscle invasive bladder cancer.

And I absolutely have patients that come in with unifocal small T1 high grade, and they’re like, “Doc, I want it out. I want it out. I want the most definitive thing. I’m freaked out by this, and I want my bladder out.” And I’ll make sure that they meet with some of our team, because I think that would, in that context, be a little bit of an aggressive first step, but it’s absolutely a guideline-directed first step. And then person B may come in with chock full T1, high grade, CIS, lymphovascular invasion, multifocal, all that, and they’re like, “There’s no way in God’s green earth I’m getting my bladder out.” And that’s also a challenging situation because I’m like, “Yeah, we could do stuff, medication of the bladder, BCG, Gem/Doce, stiladron, pembro, whatever, but I don’t think that that’s the best option for you.

So again, not to belabor, I think we’re trying to generally make sure you don’t die of bladder cancer, and select at those patients that are probably not appropriate candidates for non cystectomy options out the gates. And also make sure cystectomy has become a part of the conversation from the outset, so it doesn’t come out of left field. And we’re trying to keep people’s bladders in place safely, at the end of the day.

Rick Bangs:

And this point of managing expectations is really critical.

So we’re going to ramp it up, from a risk point of view, and so this is going to be somebody with my diagnosis, so stage two or T2, it’s muscle invasive bladder cancer. It’s high grade. And there’s no known lymph node involvement.

Dr. Aditya Bagrodia:

Yeah. So I think, most invasive bladder cancer, you’ve got my full attention. And my goals are to not have you die of bladder cancer and live a life that’s commensurate with your life goals.

Now the order of that, Rick, is, I would say, in the eye of the beholder. So those are my goals. And you know what that looks like? There’s the aggressive approach, neoadjuvant chemotherapy cystectomy urinary diversion, and there’s alternative approaches, cystectomy, postoperative, systemic therapy. If it’s merited, there’s chemo radiation, and even among chemo radiation, there’s some variability there.

So first thing, we don’t want you to die, from our perspective. We want to maintain quality of life from all perspectives. And again, just to make sure that, when we are deciding that, that the patient understands all the options, pros and cons, nuances of each one so they could pick the best one for themselves.

Rick Bangs:

Okay. So now I come in and I have been diagnosed with advanced or metastatic bladder cancer. What are the goals for a patient like that?

Dr. Aditya Bagrodia:

I think quality of life and quantity of life, and access to the absolute cutting edge standard of care, including clinical trials. We don’t want anybody with advanced or metastatic bladder cancer to die a painful and unpleasant death. We want to keep them around, respect their humanity, respect their quality of life, in a way that’s consistent with the disease state and consistent with their values and belief system.

Rick Bangs:

All right. And we’ve recently had a metastatic podcast, and the landscape is just changing so quickly in that space. So staying on top of things and potentially getting a clinical trial, particularly in this space, is probably something to seriously, seriously consider.

So what changes, if I have a recurrence, how would the goals change for somebody with a recurrence?

Dr. Aditya Bagrodia:

I do think it’s worth mentioning that, as we continue to have these revolutions, really across disease states, that the voice of the patient advocate is just beyond massive. This is kind of an example.

What about if we put you through the ringer with intensive therapy, maybe call it chemotherapy, nausea, vomiting, fatigue, lethargy, hair falling out, misery, to extend your life three months? Probably in the not too distant past, we used to do that, and if there was a significant survival advantage, everybody would be so stoked and say, oh my gosh, we can keep people with multiple refractory nasty bladder cancer alive for three months. Now, due to the patient voice, we absolutely kind of bake in as a primary endpoint patient-reported outcomes, because… The listenership can’t see you shaking your head, but I see you shaking your head. Because most people would not want to live their last three months of their life, additional three months of their lives, miserable, if there wasn’t a quality of life improvement. So I just felt like I had to share that.

Recurrences, it really varies across disease state. If you’re low risk and you have a recurrence, that’s not dangerous, typically, but I would never say that that’s not incredibly impactful to the patient. If you had a single TURBT, and two years later had a single solitary low grade recurrence, that could be a catastrophe. That could be like, oh my gosh, my cancer is back. I went from being in remission to recurrence. That’s one end of the spectrum, on the low risk end of the spectrum. If you have high risk cancer and you recur, in a non-curable setting, then you’ve automatically kind of moved into advanced and metastatic land. Or if you’ve had advanced cancer and you’ve received therapy and you’ve got a new spot pop up, that’s going to be considered a recurrence. So recurrence is a broad term, and I think depending where you are, it generally ups the intensity, ups the need to really make sure whatever’s being done is top notch.

Rick Bangs:

Yeah. And I think it also leads to some potential recalibration, just to make sure, and I think that’s true, as the journey progresses, regardless of whether you’ve got recurrence or not, but just to make sure that nothing’s changed from the patient’s perspective of choices and decisions. It may have changed. Like you said, this patient who has low grade and had the first one and then had the recurrence, the patient may be in a different place, have different thought process and different values.

Dr. Aditya Bagrodia:

Absolutely. I mean, the whole thing’s a very dynamic process. The first day, you just don’t want to die. The second day, you want to make sure that you wish to be alive, wish to be continuing to live. So absolutely, it’s dynamic. I mean, values, beliefs, understanding about the disease change. Your general health may change, which could impact things. There’s all types of things that kind of play into it.

Rick Bangs:

So you’ve made it really clear that goals may vary. So what are some of the considerations that you use as a clinician as part of this process?

Dr. Aditya Bagrodia:

Honestly, I think there’s a million every step of the way. Starting out with cystoscopies. Half the people, it’s like no big deal. Nothing happened. You could say 40% of them, it’s unpleasant, but they do it once a year. One out of 10 persons, it’s miserable. And whether that’s done with some type of anxiolytic or light sedation or in the OR, in the non-muscle invasive bladder cancer, that’s part and parcel of it.

Then intravesical therapy, whether that’s required or not required. First off, there are clinical disease states, intermediate risk bladder cancer where it’s not algorithmic that you need to put medication in the bladder and for what duration. That’s a conversation. You don’t have necessarily an imminently life-threatening cancer. Here’s the pros and cons of six catheterizations. If somebody had a catheterization and they were like, that was just beyond awful, that weighs into it. If not, that’s a little bit different. Even after a transurethral section of bladder tumor, the decision to put a catheter or not is a little bit individualized and nuanced.

Let’s say we’re going down through some BCG route, there’s some variability and lack of evidence on whether induction alone, or induction plus a year, or an induction plus three years, is the way to go. Again, some people kind of tolerate things like nothing happened, and some people, it’s quite an event and quite an affair. So there are some opportunities to kind of personalize in that context.

While on surveillance, we get tests. We obviously do the cystoscopy, with or without blue light. And many times, we’ll get a cytology. That cytology can come back as clear, negative, atypical, suspicious, or basically positive for high grade cells. What those next steps could be. It could be, let’s look again, to operative, cystoscopy, bladder biopsies, sampling of the prostate, urethra, some type of upper tract evaluation. Those are pretty different algorithms where, again, we’re taking into account the pretest probability of something bad like a cancer recurrence, and the patient’s tolerance for any given procedure.

Biopsy in full integration of small lesions in the office. From my end, sometimes we can save patients a trip to the OR, NPO, coming in two hours early, general anesthesia, all this, and that sounds pretty good. But if the patient tolerates that extremely poorly, then that’s not going to be a perfect best fit for them. So these are just some examples on the non-muscle invasive side.

On the muscle invasive side, I think, really, the impact of treatment, chemo RADS broadly versus cystectomy, with or without preoperative chemo, and the urinary diversion, these are just ultra, ultra big decisions, and making sure that patients are really educated A to Z in the nitty gritty.

Empowering patients with diet, exercise, nutrition, sleep counseling. Some patients, they’re very fit, and this is happening. Smoking cessation. Some patients really want a whole integrated team. So I think just understanding where patients are. There’s a lot of opportunities to enhance it and meet needs, versus you need chemotherapy, then you need your bladder out, then you need a conduit or neobladder, which is maybe the pillar for the appropriate patient, but there’s a lot of opportunities to take into account their say in that process.

Rick Bangs:

And their unique situation.

So I’m sure our listeners are going to be interested in hearing about your BackTable Urology podcast. So who’s the audience for that, and what kind of topics do you cover?

Dr. Aditya Bagrodia:

Yeah, yeah. So I think, like yourself, the idea of educating patients and educating ourselves in a variety of different formats. Around the pandemic, conferences had kind of gone pure virtual, really missed those conversations where it’s like, Hey, what are you doing in these scenarios? You got any cool clinical trials? What are the critical things that are important to get? And as a trainee, there was about a gazillion questions that I felt silly to ask, and it wasn’t easy to actually go to any textbook or review article or whatever and get access to those.

So the podcast was basically to create an instrument which made high yield clinical care, pearls, nuggets, in a organized way, from diagnosis to management, available to anybody, kind of starting with people that are interested in going into urology, students, residents, fellows, attendings and practitioners. What I’ve also found is that, patients really love to hear about how doctors think about their disease state. So I share podcasts with patients all the time. And essentially, the idea is ultimately to cover the full gamut of benign and cancer related topics in urology. And then sometimes, it’s really nice to talk about other aspects of, you could say, life maybe as it pertains to urology, careers of people that have really been remarkable, leadership, mentorship, just a variety of topics that might be of interest.

Rick Bangs:

So your podcast covers the full range of urology, but are there any particular insights you can remember from episodes about bladder cancers that maybe our listeners would be interested in?

Dr. Aditya Bagrodia:

Yeah, yeah. Absolutely. Gosh, all the bladder cancer ones are so good, and they’re all from people that are just ultra involved with the bladder cancer community, Eugene Pietzak and Tim Clinton, Sia Daneshmand and Anne Schuckman, Ashish Kamat. I mean, it’s really a tremendous group. But honestly, I remember one with Sam Chang, who’s at Vanderbilt University. It was just on tips and tricks for trans urethral resection of bladder tumor, and the actual podcast was supposed to be about management of high risk bladder cancer. But there was just so much to cover, even on trans urethral resection of bladder tumor that we were at an hour and never got to it.

And I think it just kind of is emblematic of how much people are interested in educating each other, how passionate they are about any given field, where literally, we never got past, how do you establish a diagnosis? And it was a fun conversation. I don’t know if you know Sam. He is an amazing guy, super charismatic. So that’s one that kind of, off the cuff, jumps out.

Rick Bangs:

Well, and it kind of makes sense because the TURBT is kind of underappreciated. It really has some nuance and some skills, from what I’m hearing. I am, of course, not a doctor, but that’s what I hear from urologists, that it really is something that needs to be done very careful and with a lot of expertise.

Dr. Aditya Bagrodia:

Yeah, yeah. It’s not just a biopsy, I’ll assure you.

Rick Bangs:

No, it’s not a simple thing. Even though it’s common, not a simple thing.

Dr. Aditya Bagrodia:

That’s right.

Rick Bangs:

Any final thoughts?

Dr. Aditya Bagrodia:

Well, Rick, again, thank you so much for having me on the show. I hope this does empower patients, once again, to just ask the questions, educate themselves. I mean, it’s so nice that there is a comprehensive resource, vetted by patients and providers, that really covers the gamut. It’s a wonderful resource that you provide. So to me, it’s an honor to be here.

We’re so super excited that the think tank’s going to be in San Diego 2024. I think the bladder cancer community is really interested in helping understand what’s important to patients, engaging in shared decision-making so they can have the best outcome and not regretting decisions.

Rick Bangs:

I absolutely agree, and it’s been an honor to have you as well.

So, Dr. Bagrodia, I want to thank you for helping us better understand shared decision-making and goals of care in the bladder cancer context. 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 your email, Twitter handle, or a website for the BackTable Urology podcast?

Dr. Aditya Bagrodia:

Yeah, yeah, absolutely. So my Twitter handle is @AdityaBagrodia. That’s not an easy one to spell out, but you can come across that one pretty straightforward. My email’s bagrodia, B-A-G-R-O-D-I-A, @health.ucsd.edu. And we’re super thrilled to post this through the BackTable channels, and you can find all episodes of our podcast on iTunes, Spotify, and at backtable.com.

Rick Bangs:

Excellent. 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. Be sure to like, comment and subscribe to this podcast 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. Bagrodia.

Dr. Aditya Bagrodia:

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, 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.