Transcript of Veterans and Bladder Cancer: What You Need to Know with Dr. Joshua Meeks

August 2, 2022

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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 CGEN Astellas, EMD Serono Pfizer, Genentech, and Merck.

Rick Bangs:

I’m pleased to welcome today’s guest Dr. Josh Meeks. Dr. Meeks is Section Chief of Robotic Surgery at the Jesse Brown VA Medical Center, an Associate Professor of Urology, Biochemistry, and Molecular Genetics at the Northwestern University Feinberg School of Medicine. He is a urologic surgeon with expertise in the diagnosis, treatment and management of bladder cancer. He received his MD and PhD degrees from Northwestern University in 2005, completed urology residency at Northwestern University in 2011, and a urologic oncology fellowship at Memorial Sloan Kettering Cancer Center in 2012. His research interests focus on mutations associated with cancer biology, and he’s also a member of the BCAN Scientific Advisory Board. So Dr. Meeks, welcome. I’m so excited to have you join me on today’s podcast.

Dr. Joshua Meeks:

Thanks for having me, Rick. Really excited to be here and participate today.

Rick Bangs:

Glad to have you. So can you tell us, how did you get started at the VA?

Dr. Joshua Meeks:

Well, so as you mentioned in the intro, I did a residency here at Northwestern and our VA affiliate is Jesse Brown. And so most of my training, we do a good amount of time at Jesse Brown. We go there for three separate tours during our six years of training each one, three to four months. So my clinical training had really benefited from being able to work at Jesse Brown and so I had a really strong affiliation there. And then I was at Memorial and was pretty sure I was going to be taking a job there and was planning to stay at Sloan Kettering. And then at that same time, I heard from the surgery chief at Jesse Brown that said we actually got a robot and it was one of these things where it was 2000, and I want to say 11, and the VA was kind of behind the times with adopting the robot.

Dr. Joshua Meeks:

And so at this point, the VA nationally had purchased a robot for Jesse Brown and it arrived on the door, this big crate with the surgical robot arrived. And they said, “Well, we’re also going to give you a full time position for someone to do this.” And so they had a position available and it was an opportunity to really come back to Jesse Brown, develop a robotics program, which I knew would be helpful to our patients, but then part of working at Jesse Brown as the affiliate at Northwestern. So it allowed me to develop a practice at the VA to really do good surgery, to do good patient care, have a practice at Northwestern, but then also have my research laboratory and be able to work back and forth.

Dr. Joshua Meeks:

So it was really a unique environment and it had all of the right people and really, there were very good role models when I came to interview that were, what I had not seen before really, surgeon scientists that were able to be successful working at the VA and still doing good, good work. And so that was just an opportunity that I couldn’t pass up. And again, this was almost 10 years ago.

Rick Bangs:

Wow. Sounds like a great opportunity. But is there a standard entry point or drive for doctors or nurses who work in the VA setting?

Dr. Joshua Meeks:

It’d be hard for me to answer for everybody. And especially, it’s hard for me to say for our nurses, because I just don’t know how that road gets there. I’ll tell you for physicians, there’s two kind of models. For example, there’s different VAs across the country where there’s very good surgeons who come there once a week, twice a month. And in that case, they really put people on the schedule so that they can get treatment from these outstanding providers. But it’s really more of a limited model. And then there’s other physicians who are like myself, who are either full-time or nearly full-time, and that’s part of why they join the institution and really it’s a chance to do something a little bit different.

Dr. Joshua Meeks:

And I’ll say that the real reason why I think that’s becoming more and more of a good environment for young physicians is that as a provider where we have a lot of opportunities, but the opportunity for research and the opportunity to really enjoy their practice and not chase, for example, RVUs, is really the benefit of the VA, the fact that you can take care of your patients, do a good job for them, but then have a very strong academic environment. I mean, that fights against the challenge of burnout that many providers chase in the middle and end of their career because the environment is a rewarding place to work.

Rick Bangs:

Yeah. Sounds like the best of both words, both the research side and the patient-centric side. So that’s wonderful. So how common is bladder cancer within the VA system?

Dr. Joshua Meeks:

Yeah, so much of the epidemiology of cancer and clinical disease and the VA mirrors if you look at men throughout the US, so very similar to what we find in our male population in the entire US. It’s the fourth most common cancer, so prostate lung, colon, bladder. Overall, there’s somewhere between three to 4,000 new cases a year in the VA. And those numbers, one of the benefit of the VA is that there’s a very good record as far as codes and treatments and such, and that probably is where that gets you that three to 3,500, but there’s a lot of patients who may get part of their care at the VA. So that could be underestimated by almost 50%, the number of veterans that have bladder cancer that are cared for in some capacity by the VA.

Rick Bangs:

So I’m curious about the options that would be available to a bladder cancer patient at the VA. Can I get multidisciplinary care, in other words, a medical team with all the different specialties relevant to bladder cancer, like a surgeon and a medical oncologist and a radiation oncologist, would that be available to me?

Dr. Joshua Meeks:

Well, I would say very similar to what you would anticipate you could get in one geographic area, you should be able to get that at every VA. So let me talk a little more about that. So in Chicago, I would say that the amount of opportunities for care are going to be pretty variable. You go to certain hospitals, you’re going to find those doctors that specialize in certain things and others not.

Rick Bangs:

Right.

Dr. Joshua Meeks:

For example, the care I could provide at one hospital may maybe different than even a suburban hospital. So we can agree that there’s asymmetry in bladder cancer care outside of the VA. I think that the difference within the VA is that we have a much higher threshold for the amount and the quality of care that every veteran should get.

Dr. Joshua Meeks:

So I mean, that asymmetry shouldn’t exist, for example, in rural Montana. Those veterans should be able to get the same kind of care that you could get in an urban VA, for example. So I think we have a higher threshold of what we expect for that quality. I’ll tell you that, for example, at Jesse Brown, you have access to all those providers. You have a surgical team. You have radiation oncologist. You have medical oncology. It’s actually in many ways, easier for everyone to get together. So all of that is present. But do you have, for example, medical oncology specialization in different parts of the country? And I’d say that the answer may not be true there. But what is really truly innovative is, for example, the VA has a telecommunications and oncology where you could have a provider in Durham caring for patients in rural parts of the country in coordinating care with pharmacists and nurses to give that patient chemotherapy.

Dr. Joshua Meeks:

And so that telemedicine or teleoncology is already happening. And that was responsive to the fact that again, you have to raise the the water for all the ships. And so again, the benefit is that you can try and reach out nationally. Again, we have national guidelines. We follow patients nationally to make sure that every patient can be identified. For example, you can identify all the patients in the VA with bladder cancer, every single one of them. I determine how many of them have had TURBTs, how many have had cystectomies. In the US, 200 cystectomies or so happen a year and you can track that. So that’s really the benefit of having such an interdigitated system where everybody is linked together. So I’d say that in general, overall bladder cancer care I wouldn’t say is asymmetric, but the goal is to get everyone to a better spot.

Rick Bangs:

That makes sense. And full disclosure, my father got care at the VA locally for ALS and they were just phenomenal. So that’s great.

Dr. Joshua Meeks:

And I would say just to expand that, just to touch further, Rick, is that even though that the surgeries are the same, the surgery we would do at one hospital is the same as the other, I think all the stuff around it really is a better place for veterans at the VA hospitals. And what I mean by that specifically is the social work is there. The rehab is there. All the different stuff that really is meant to engage the veteran that we honestly wish that we had outside the hospital, the VA brings that. So I answer that just as a purely medical approach, but it’s really that shell around it that you really get the benefit of that at the VA which obviously is going to be depend on a lot of other factors at our other hospitals.

Rick Bangs:

Yeah. You don’t always get that in some of the community settings. So talk about, and I think the answer’s going to be very consistent with what you just said, but from a treatment point of view, I’m assuming I can get VCG, I can get immunotherapy, I can get a radical cystectomy with a neobladder. Talk a little bit about treatments.

Dr. Joshua Meeks:

And again I’m biased by being at one VA institution. And I’ll tell you, there’s a really good society of urologists that participate in care for veterans. And I’ll tell you that the issues they address are very similar to what you would hear at university affiliates. So intravesical BCG, do they have access? Yes or no. Intravesical chemotherapy treatments for BCG and responsive disease. I mean, those are all things that many of us deal with outside of the VA that are the same. I think where it comes to a little bit difference is, well, for example, radical cystectomy. Do you have the right surgeon and team in ICU? And I’ll tell you at many of the big urban VAs or those that have access to all the right pieces, that by all means happens.

Dr. Joshua Meeks:

The other opportunity is community care. If a veteran’s in a place where they don’t have access to what they need, then community care is certainly an option for patient to get the care they need at the affiliate and then come back for follow up. So I think, again, we really try to establish that bar that just because I think a good example is radiation. So at Jesse Brown, for example, we don’t have radiation oncology. Hines is, gosh, what eight miles away? I mean, it’s not very far and that’s where our veterans go for radiation treatments. But if they, for example, live far away and can’t make that, then community care is an opportunity for them to get the same level and kind of care, and then be able to integrate that back into their treatment.

Rick Bangs:

Okay. So for some of our veterans, there’s a connection between their service and bladder cancer. So I’m curious what makes up some of those connections?

Dr. Joshua Meeks:

Yeah. And again, the service connection is another part that really is a provider I just have less information about, how someone establishes it. And what I would really refer our veterans to is their individual VA and if they think they’ve had, for example, a lot of it comes to exposures during service, whether they’re combat related exposures or non-combat related exposures. But if they have concerns, if they’re at all worried, they should just be in touch with their VA. And we can provide that information to them about who they should be reaching out to at their own local sites. But I think from an exposure, I think we all worry about environmental exposures. And again, we’re doing a session this year at BCAN at the Think Tank about going from this concept of environmental exposures to actually how people get cancer.

Dr. Joshua Meeks:

And, and boy, Rick, as you know it, that’s a huge black box. I mean, we know about smoking but that’s probably 50%, in our veteran population, definitely a higher risk of smoking. We think in general right now for the people who use the VA, anywhere from 60 to 70%, are considered either current smokers or one time smokers. We’ve looked at bladder cancer in the VA. It’s at some point 80 to 90% of people who have bladder cancer were a smoker, but we just don’t have a good sense of that black box of exposure and how much and when.

Dr. Joshua Meeks:

Now the DOD is doing a good bit of work in that and that’s been being measured as far as what people are exposed to during deployment. I think we’re going to be able to take a little bit of that black box and break it down more. I’ll tell you now that the big ones that we think about that certainly are service connected, Agent Orange, Camp Lejeune. I mean, those are the big exposures that we have have been linked to bladder cancer in the veteran population.

Rick Bangs:

Okay. And I want to ask about one of your keen interests which is cancer research. And I think our listeners would be surprised to know how much research the VA actually does.

Dr. Joshua Meeks:

Yeah, boy. And I’ll tell you, it’s really one of the major. In addition, the clinical care, the research that comes from the VA and what it supports is again, I had no idea that this occurred 10 years ago as far as the amount of research that the VA supports. So bladder cancer has got a special place in the VA research portfolio. And a lot of that is because of its service connection. And I’ll tell you, just to give you a sense of what that is, so the VA has a Precision Oncology Initiative that actually began with lung cancer. And as you know, there’s a lot more precision targets from lung cancer than there is for other solid organs.

Dr. Joshua Meeks:

But after lung, there’s now this GU Precision Oncology program. Eight sites currently, and then if you occlude the prostate sites, which are really part of the bigger umbrella of GU precision oncology, it’s almost double that many. And it gets at this question of can we apply precision care in the VA across the country to improve the quality of care? And this really isn’t even a research question as much as trying to develop precision approaches for patients to really increase activity of drugs, but also decrease toxicity and harm. And again, the VA is trying to approach this at a national level. And just to give you an example, so any veteran can have their tumor sequence through foundation medicine, and all that’s available to the providers throughout the VA to better treat them. So you can imagine in any community setting to get a tumor sequence, it takes the provider. It takes a lot of people.

Rick Bangs:

Right. Because that’s cutting edge.

Dr. Joshua Meeks:

But within the VA, that can be done seamlessly with results back in a few weeks. And then again, that’s all part of nationally being able to treat that patient. So I really think that the VAs ahead of that. Now, one thing that they’re interested in specifically in bladder cancer goes back to there there’s trials, so the VA can run clinical trials at multiple institutions through an application process that’s reviewed twice a year. There are trials and bladder cancer that are open and accruing at VAs. And then there’s two specific ones in early stage. So example, we have a screening trial that we’re trying to get the VA to support that would be a 24,000 patient veteran screening trial. Because again, as you know, there really is no screening for bladder cancer. But we think, for example, our veterans would be interested in this and we think they’re at risk enough where this would be something that could find cancers early, detect them early and potentially improve survival.

Dr. Joshua Meeks:

And then on the other side of it, there’s also thoughts that are we doing the right amount of surveillance and is there a way to do that in a different manner? I mean, those are just two examples of trials that the VA is interested in and is cultivating right now. So I think for, for both our patients as well as investigators, there’s a lot of opportunity within the VA. And that doesn’t include anything from the NCI side, which again, the VA’s working to better integrate veterans into NCI clinical trials and provide access to them.

Rick Bangs:

So at the VA, you might get a VA trial, you might participate in a trial that the NCI, the National Cancer Institute is sponsoring, there might be some other studies. It’s all of those things are possible options in a VA setting, right?

Dr. Joshua Meeks:

They are. I’d say that right now what’s a little bit underappreciated is that to open an NCI trial at a VA, usually those are academic affiliates. So for example, Northwestern is a SWOG affiliate. So we’re able to open any SWOG trial here. Well, for Jesse Brown to do that, it would be usually through the affiliate, meaning Northwestern would have to want to open that as a sub-site. But that barrier is kind of being broken down by several factors. One, they’re trying to develop this storefront where multiple VAs can come in. Additionally, there’s this Navigate program where specific VAs like Hines, for example, is actually affiliated with the NCI and able to open trials. So there’s a lot of barriers that were present that are trying to quickly be broken down to allow veterans access to these potentially lifesaving trials and let them be involved in order to participate.

Rick Bangs:

That’s that’s absolutely terrific. So there’s a partnership between the National Cancer Institute in the VA, and I believe it goes by the term Navigate.

Dr. Joshua Meeks:

Yes.

Rick Bangs:

So can you talk about what is Navigate?

Dr. Joshua Meeks:

Yeah. And again, I’d have to say that I know less about Navigate. Jesse Brown. Isn’t a Navigate side. Hines is, but it’s really about providing resources and coordinators and trying to bring that connection, that again normally would be at an affiliate, to the VA in order to really facilitate opening these NCI trials and allowing for accrual to occur. I mean, you think about all the resources at a cancer center that are present, the CTO that’s involved in opening trials, running trials, the budgeting offices. That’s a lot of resources that happen behind the scene that I don’t think a lot of patients know about. Huge costs to get all that going. And there’s an activation energy that you need to put together in order for the trials to occur. And as far as I can tell, the goal of Navigate is to bring that or allow that to happen in the VA setting so that, again, veterans can be involved in those trials.

Rick Bangs:

Yeah. I think you’ve raised an important point which is as patients, we kind of think of clinical trials, if we think of clinical trials at all, we think, “Oh, the doctor’s just going to ask me,” and then and all of this infrastructure that you need to make that simple ask happen is not so simple.

Dr. Joshua Meeks:

Yeah. I mean, again, I’m sure you’ve mentioned on your show before, but most trials are between six and 12 months of startup time from the time that a physician says, “I like that trial and want to open it.” There’s so much behind the scene that happens to get that first patient in. And believe it or not, once that first patient’s enrolled, it’s actually kind of off to the races. But that infrastructure, that’s really critical, and again, the VA realizes that that needs to be facilitated.

Rick Bangs:

Yep. All right. Now, is there anything else you want to mention regarding the VA and bladder cancer?

Dr. Joshua Meeks:

Well, I really think that there’s so many opportunities for our veterans to participate in trying to help us understand the cancer. There’s opportunities for our providers who have an interest in bladder cancer to really investigate why people get this cancer. And I just think that, again, it goes more than service and it goes back to the opportunity that we can really work on our bladder cancer community in the VA. So really, if there’s providers in and patients interested, that this should be a very good place for everybody to kind of work together.

Rick Bangs:

Yeah, absolutely. So, Dr. Meeks, thank you for your time today. You’ve given us a nice introduction into the great work that the Veterans Administration does for the bladder cancer community and the exciting research that it conducts. For more information on bladder cancer and veterans, please visit the BCAN site at bcan.org and search for veteran resources. In case people would like to get in touch with you, dr. Meeks, can you share your Twitter handle so people can find you?

Dr. Joshua Meeks:

Yeah, so my personal Twitter account, not affiliated with the VA, is @JoshMeeks. I do post near most things related to bladder cancer there so happy to engage anyone. Thanks.

Rick Bangs:

Wonderful. Wonderful. If you’re in the Chicago area, you can contact the Jesse Brown VA at 312-569-8387.. And outside the Chicago area, you can go to www.va.gov. 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. Thank you for listening and we’ll be back soon with another interesting episode of Bladder Cancer Matters. Thanks again, Dr. Meeks.

Dr. Joshua Meeks:

Thanks, 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.