Transcript of What Are Bladder Cancer Guidelines and Why Do They Matters to Patients with Dr. Thomas Flaig

April 25, 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 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 Seagen/Astellas alliance.

I’m pleased to welcome today’s guest, Dr. Thomas Flaig. Dr. Flaig is a genitourinary urinary cancer medical oncologist and vice chancellor for research for the Colorado University, Denver and Anschutz medical campuses. In addition to his clinical and administrative work, Dr. Flaig has significant clinical and translational research experience, having led both local and national multi-center clinical trials. Known nationally for his work in bladder cancer, Dr. Flaig has been a member of the National Cancer Institute’s Investigational Drug Steering Committee and the Bladder Cancer Task Force. He also serves as chair of the Bladder Cancer Panel for the National Comprehensive Care Network, AKA, the NCCN, which publishes internationally recognized treatment guidelines. Dr. Flaig, thanks for joining our podcast.

Dr. Thomas Flaig:

Well, Rick, what a real pleasure to join you today and be part of this podcast. I’m glad to be here and looking forward to our discussion today.

Rick Bangs:

As am I. So first we have to have a full disclosure here, and that is that our listeners should know that you and I work together the National Comprehensive Cancer Network, the NCCN Bladder Cancer Guidelines, and we also work together on clinical trials at the SWOG Cancer Research Network, which is one of four adult cooperative networks funded by the National Cancer Institute to design and deliver clinical trials that will change the standard of care available to patients. So I want to start the guidelines discussion with some fundamentals, which let’s start with the obvious question. What are guidelines and why should patients in the survivor community even care about them?

Dr. Thomas Flaig:

So what are guidelines? It’s a fundamental question. It’s a somewhat difficult question to answer in some ways. I would say guidelines are just that they’re guides, they’re not rule books, and I make that differentiation from time to time. They’re guides. And what they try to do in my mind is capture a consensus on the best way to address a clinical problem. And again, a lot of these guidelines are focused on diagnosis, treatment, follow up, some things in that regard.

And in some cases, guidelines can reflect evidence. And so you’ve got a panel of individuals and researchers and patient advocates and others who interpret the evidence. And sometimes they’re largely based on expert opinion, and the consensus is found by bringing together a group of people that can really describe that expert opinion consensus.

I would say guidelines can be around diagnosis, treatment, follow up. They can be sometimes for specific groups of patients, for example, adolescents, young adults, or patients with cancer and HIV. They can also be for specific regions when we talk about this later as well. So you can have guidelines that are for particular resource levels or particular geographic regions, for example.

I think in some ways there are a way for us to think as a starting point for therapy. You have to customize that to individual patients and so forth, but they’re a starting point. They’re a way for us to keep updated and another way for clinicians to check and say, what is the consensus opinion about a particular area or disease?

Rick Bangs:

So patients should care about them because the experts have defined them? What’s the real reason the patient and cancer community should care about them?

Dr. Thomas Flaig:

Yeah, thanks for coming back to that, Rick. I think patients should care about this because they’re an important part of the way that delivery is made. So for a patient who’ve seen a provider, for example, the NCCN, which you’ve mentioned, both of us are a part of. Those guidelines are downloaded 13 million times a year. So it’s very possible as a patient that your care is being informed or influenced by guidelines that the clinician, your providers, are using.

We also say that there are guidelines that are developed for patients specifically. In some cases, those are professional guidelines that have been adapted for patients. I would say this, I’ve spent a lot of time thinking about guidelines and how they’re used, and it’s really important to have high quality guidelines because of the role they can play. So again, imagine a busy clinician they had maybe heard a few months ago, there’d been a development in a field, in a field they follow or don’t follow, what have you. They can go to a guideline and look and see what the current consensus of belief is in that. And so again, for a patient, it’s important that your providers have a place they can go for that. And secondarily, or maybe even primarily, there’s a place that they can go to understand the consensus view on different things themselves.

Rick Bangs:

Yeah. That’s so important. So these guidelines get targeted to different audiences. You kind of hinted at that, but could you talk a little bit more about the different audiences?

Dr. Thomas Flaig:

Yeah, thanks for letting me speak about that too, Rick. I would say a lot of the guidelines, so if you just think about them, they’re for clinicians, they’re for providers, they’re for specific treatment, diagnosis, disease, patient population. And that’s probably where a lot of these started. There has been, I think, a very appropriate push over recent years to have patient-specific guidelines. So hopefully the same information but with a lens towards patients and then a language that’s accessible to patients.

We also say audiences are different based on geographies for a variety of reasons, or I think even maybe more appropriately based on resource level. Again, a guideline that’s based the United States or in Europe perhaps is at a high resource level. When you think of drug availability and scans and all sorts of different things. Guidelines can be specific for the resource level of where the care is being delivered. And again, I think that’s a very important consideration and several of the major guidelines are trying to think through that in a thoughtful way.

Rick Bangs:

Okay, so now who are the men and women behind the curtain? Who’s defining these guidelines?

Dr. Thomas Flaig:

The guidelines are made up of panels, and you could say how many different guidelines are there. There’s a lot of different guidelines. And if you go back to maybe how many of these started, it was a specific professional society. So it could be, again, in our field of bladder cancer, it could be a professional society of medical oncologists or professional society of urologists or one geography.

But over times, these panels have become more and more multidisciplinary, and I think that’s the best way to do it myself. So you have medical people, radiation oncologists, surgical specialists, all coming together. I think ideally a panel would be reflective of that. There may also be addition appropriately of patient advocates and other people that are in this realm. In some cases, perhaps primary care providers who would play a role, particularly in some of the screening and diagnostic-based panels. But at the end of the day, these are people that are considered experts or represent a certain point of view that come together, review data, review submissions and evidence, and try to find a consensus among those different data points.

Rick Bangs:

And if you had to guess, how many different bladder cancer guidelines would you think there might be?

Dr. Thomas Flaig:

It’s an interesting question, Mr. Bangs. I don’t know if that’s what I quite thought through before. There are multiple guidelines though, and you can see them again for individual professional societies. So off the top of my head, I can think of three or four if not more. And several of those have combined. So rather than just saying, here’s a medical professional group or a surgical professional group point of view, I’ve seen more and more consolidation of these. They’re multidisciplinary. There’s clearly a number in the United States. There’s clearly one or two in Europe, different constituencies around that. And I think the tricky part for both providers and patients is these guidelines may not always agree for a variety of reasons, no matter how many numbers there are out there.

Rick Bangs:

So let’s talk about what it takes to generate these guidelines. And if I were to look at a single guideline within the NCCN bladder cancer guidelines, what is the work that would’ve proceeded it?

Dr. Thomas Flaig:

Yeah, so I’ll speak a little bit about the process with the NCCN. I think it’s similar from any of the guidelines. So there’s a couple of significant inputs. I think anybody doing guidelines would want to look at the literature at a regular time point. So for example, once a year to look at the literature in your field, whatever your purview is or your charge to see what’s changed there. One of the things that the NCCN does is specifically have the institutions do a review on a regular basis to say, as you’re using these guidelines, what would you like to see differently? Or what needs to be updated or what needs to be discussed? I think it’s also healthy for guidelines to take external submissions from patient advocates, from providers that are using guidelines that say, this isn’t matching up or this isn’t complete and so forth. So again, you’ve got literature review, you’ve got institutional reviews and expert reviews and outside sources that come together and then are put into that review and that panel process.

Rick Bangs:

And so now preceding the publication though is going to be some kind of research, typically a clinical trial, right?

Dr. Thomas Flaig:

Oh, right. Yeah. I think one of the tricky things you might be getting at there is let’s say we’re attending a scientific meeting. In fact, again, for patients and others that are watching the evening news, they might see a report from a meeting and see an update. This drug was being tested or what have you. And so you might get early data, but it’s not peer reviewed, it’s not a full manuscript. And then maybe later you’ll get to see that full peer reviewed. So the literature can have different levels of both peer review. And by peer review, I mean it’s been submitted, it’s been anonymously looked at by experts in the field, peers if you will, who give that feedback, and then if it’s finally approved, it’s based on that review of peers in the field.

So I guess to your point, the literature can be at different levels. Everything from a median abstract that’s not been reviewed by really a peer to something that’s in the literature, and the panels need to take those different levels of evidence into play.

The other thing I’d say is you can have a single arm trial where it looks at a group of patients. There’s no comparison arm. It’s a small group and looks at a finding. You can have a several thousand patient randomized study with two different groups, which would give you a different level of evidence. So the ability to look at the level of evidence in these different literature sources is a critical part to any review process.

Rick Bangs:

So let’s talk a little bit more about, we’ve done the clinical trial, and so how do we get from that to the publication changing the guideline? I think you’ve hinted at some of it, but tell us a little bit more about that.

Dr. Thomas Flaig:

Yeah, so the clinical trial is a couple different stages. One is you accrue the patients. Now interesting, you’ll finish accrue the patients. Then the trial will be closed to accrual, and we’ll sometimes see that this trial’s closed. But the next thing is then to, and by accrual I mean that all the patients are enrolled that you want to see for the trial. And then after that, you have to wait for the results. And so what happens, that can be a long wait. I’ve had patients say, “I know that trial is now closed. What are the results coming out?” And I think what I have to say oftentimes is, “We don’t know. It could take a year or two.”

Then the results come out, and those are oftentimes in a meeting. So again, you’ll see somebody present this, it’ll oftentimes even make the news, the highlight. It’s usually a half a page or a couple of paragraphs, but it’s got the key information. However, that has not gone through what we call a peer review process by which it’s been submitted in full form, the full manuscript reviewed, feedback and so forth.

The next phase though, is that step, that peer reviewed where a full protocol is submitted to a journal. The journal will have two or three reviewers that look at that. They’ll make an assessment. There’s usually a back and forth. And if it’s accepted, it’ll be at that point peer reviewed.

So at that point, we then have a peer reviewed manuscript from the protocol. And at that point, guidelines could look at that with confidence to say, this is now in final form. The protocol is available and it’s been peer reviewed. And then you could look at the level of evidence. Is this a large study? Is it small? Is there a control arm? Is it a single arm of the study in which patients are treated? And make an assessment about the level of evidence behind this.

Rick Bangs:

So the panel has kind of its own peer review process, in the sense that people on the panel are looking at this evidence and they’re making some judgment as to how rigorous this evidence is, and whether or not it should dictate a change in the existing guideline or a new guideline, for example.

Dr. Thomas Flaig:

Because these panels, whichever one we’re talking about, would have experts in the field, they can interpret the data from the studies. And one point, I don’t know if I’ve made it as well as I want to, you generally want to wait for those peer reviewed publications come out, the full manuscript has been looked at under this process.

And then when you get that data, you can interpret it. Do we agree with the way it’s designed? It’s been accepted, it’s been reviewed, but do we agree with that? How does this line up with existing data? We had some standard before this. Does this change the standard of care? Is it something less than that? Do we want to see another study that might be in process? That’s oftentimes a case in bladder cancer. We’ve been very successful with trials. We may want to see another study that’s underway to see results of that to put it into place. So you’re exactly right, Rick. I think the role of the panel is to interpret those study results. The fundamental question is, does this change the standard of care? And if so, how does it add to that? Is it a alternative to the past standard? Does it displace the past standard? And those are very important decisions.

Rick Bangs:

And so these different guidelines that we talked about, and you mentioned that there might be 2, 3, 4 or whatever in the US and then internationally, would they all leverage the same evidence?

Dr. Thomas Flaig:

I think they would all have their own process to review the literature, but the literature is what it is. In other words, we in the United States would look at the European and larger global literature that comes in. People working in other part of the world would look at the literature we do and so forth. So literature has become global. I think what might be different are the experts you have on these panels. I think the standard of care and available drugs are different. So for example, we’ve been saying Europe a lot, but for example, Europe has drugs that we may not have available or vice versa in some situations. The availability of a certain scan. It might be easy to get a certain scan in one environment, one geography where it might be more difficult. So you see differences there. But fundamentally, this might come down to how the experts weigh and measure new results against what we have before. And that is, again, that expert opinion part of any guideline development.

Rick Bangs:

And there also might be timing differences, right?

Dr. Thomas Flaig:

Timing the sense of when the data’s available?

Rick Bangs:

Yeah. Or when the guideline is published versus the publications.

Dr. Thomas Flaig:

Yeah. Because the groups can do this differently. Guidelines groups can do this differently. They could say, “We’re going to meet once a year, every three years,” or something like that. They can just say, “We’re going to have a static meeting schedule.” And then at that time point, let’s say they’re going to meet every two years, we will review the literature and do it that way. Other guidelines would say, “We are going to adapt whenever there is a change, whether that means once a year or 10 times a year.” And it could mean either. And I think that’s the difference between guidelines that you could see.

Rick Bangs:

Okay, and we’re going to come back to this because over the time that you and I have known one another over a decade now, the amount of information flowing in to change the guidelines has changed significantly. So the frequency of updating is increased substantially. So if I wanted to, and you know I’m a high involvement patient, if I wanted to, could I review the bladder cancer guidelines relevant to me as a patient?

Dr. Thomas Flaig:

Sure. For example, these guidelines are available through different sources. They’re public, they might be behind some sort of journal or something. So to get into it, some guidelines you need to sign in for free in various ways. But patients can certainly access what I would call the professional guidelines, the guidelines that providers are using.

And I would say in practice, when I’ve seen patients, I’ll occasionally have patients come in with some printed pages and they’ve circled some areas, and we’ll go through those together. And I think the challenge there is that us doctors will use some abbreviations or shorthand, and it is hard to figure out one type of patient where I said RT in a few places, that was radiation therapy. I mean, I knew that, because I knew the context of the whole thing, but it was very hard to figure that out.

I would say that patients also have access. And again, there’s been a large effort to have patient-specific guidelines. And so that’s another way of approaching this. And an I think an approach that uses less acronyms, jargon, and some of the things that are part of the medical lexicon.

Rick Bangs:

So let’s take our listeners behind the curtain and talk about the process of generating the patient version. And we can specifically talk about the NCCN guidelines. So what’s the process to generate the patient version?

Dr. Thomas Flaig:

So again, we’ve got a couple versions. One is the professional version, the version that providers use, jargon, hundreds and hundreds of references and this sort of thing. I think the goal of the patient guidelines is to have largely the same data, maybe a little less detail, but have it in a format that’s accessible to patients. So there’s a professional staff at the NCCN, for example, that does this work and has many patient guidelines that have been developed in this light. And this would include feedback from experts in the field, those professional experts, the physicians and researchers in the panel, as well as patients to make sure we’re hitting the mark. It’s an important thing to do, and I tell you, it takes some real expertise to do that, to translate it from one lexicon to another in an accurate way.

Rick Bangs:

Yeah, plain language is not a simple thing, nor is everybody gifted at it.

Dr. Thomas Flaig:

I agree and I agree.

Rick Bangs:

Okay. So now if you can answer this question, how often do guidelines change and why would they change?

Dr. Thomas Flaig:

So again, Rick, you mentioned that you and I have had a chance to work there for a long time. And I think one of the changes that I’ve seen in my involvement in bladder cancer guidelines is that seven or eight years ago, we weren’t meeting very often. There were not, and maybe it’s even a bit beyond that, there weren’t a lot of new advances, and we could almost meet once a year and have it. In other times, more recently for bladder cancer, we’ve had a lot of approvals and FDA updates and FDA approvals and new phase three trials that have a chance to change the standard of care.

So I would say there are times that guidelines that are going to be kept up to date to the minute, not something that gets done every two or three years, would need to meet regularly multiple times a year to do that. And again, if you look at the NCCN, and you can look beyond bladder, other guidelines, you’ll see version 2022, version four or five or six sometimes for different guidelines. I don’t have to look to what bladder gets up to, but we will regularly meet in that setting to update guidelines if we think there’s been an impact on how we should treat patients, which is a big commitment. It takes a lot of resource to do that on the fly, have the right support staff around to do it in a reproducible and robust way.

Rick Bangs:

So the more often folks like you and I are meeting to change the guideline from a patient’s point of view, that’s probably a good thing.

Dr. Thomas Flaig:

Absolutely. The alternative is not good.

Rick Bangs:

No, no. So there’s some areas where there aren’t a lot of guidelines. So could you talk about what those might be in the bladder cancer space?

Dr. Thomas Flaig:

Yeah, and Rick, I’d be happy to get your perspective of this too, because I would say there’s some areas in which there’s not a lot of data. They’re rare situations. There may be rare histologies that aren’t seen very often, rare presentations.

And I would also say this, it’s for someone that sees patients and regularly uses the guidelines intentionally, I try to pull them up and say, “Was this helping me in this particular patient?” Sometimes patients just don’t fit, and I don’t know if that’s getting at right now, but it’s certainly the case that a patient who comes in doesn’t fit whatever trial we’re trying to reference, whatever, and you have to customize it to that patient. Survivorship might be an area too, I think you and I have talked about as an area of guidelines and maybe an area where some additional guidance can be made. I think providers will oftentimes, not necessarily all providers certainly, but think that the follow-up plan equals survivorship. And obviously there’s more to that. A lot of groups are giving more emphasis appropriately to that area. But maybe I’ll ask you too, Rick, what areas do you think maybe the guidelines aren’t as robust?

Rick Bangs:

Yeah, I think this last point that you raised is the one that comes to mind where you get around five years and there isn’t a lot of data suggesting how often, and again, there’s art to it, but how often should you get surveillance? And for my neobladder, should I continue to get B12 readings and those kind of things? It gets a little less clear and a little more calibrated to a specific situation and discussion between the doctor and the patient.

Dr. Thomas Flaig:

I would agree. I would agree that Rick, this is a very important area, and I would say if we think of the literature that we try to cite for different things, take that randomized control trial with a thousand patients, helps us. We have very little research being done in this area, I would say, and maybe that’s one of the larger emphasis, people ask me, they say, “Hey, Tom, you do a lot of research. Tell me about this guidelines. How does that fit in?” To your point earlier, the research drives the guidelines, right? Interpreting the research, applying the guidelines. If we have research, we have findings… This survivorship area, really, what if we check B12 levels every two years for life? What if we stop at five years? If we detect [inaudible 00:22:30], what’s the level of evidence to help guide us there? It’s not good. So maybe the theme here is that we need to have better research on this area because I think all the guidelines would respond very well to clear evidence to guide how we write these guidelines.

Rick Bangs:

So now what’s unique and evolving about the guidelines in our context, bladder cancer?

Dr. Thomas Flaig:

Maybe it’s what I alluded to earlier, in that the guidelines, it’s been a busy time to be anywhere in the world working on bladder cancer guidelines and that is a very good thing. There are a lot of abstracts, there are a lot of publications, there’s a lot of drug development going on here. To me, again, let’s take it at a very high level. We are going from having a number of monotherapies that have been introduced, immune checkpoint inhibitors, antibody drug conjugates, targeted therapy with erdafitinib. Okay, we’ve got these drugs. How do we best sequence them? How do we best combine them? How do we select patients with biomarkers who should get therapy X, Y, Z? So it’s kind of the maturation of saying, great, we’ve got a bunch of new drugs and therapies. We’ve been waiting, we’ve got them. How do we combine them? How do we consequence? How do we best use these together? And that’ll be the challenge, I think, for care and for guidelines in the coming years, five years or more.

Rick Bangs:

And the guidelines five or ten years ago, wouldn’t have even had some of these agents.

Dr. Thomas Flaig:

Oh, no.

Rick Bangs:

Yeah.

Dr. Thomas Flaig:

I don’t know if you’ve done that, Rick, if you look back just 10 years, how thin the guidelines were and how little evidence there was. We didn’t have new drugs really, 20 years.

Rick Bangs:

Oh, I know. Or more. Well, we’re in a better place and we’re making huge progress, but there’s still so much we don’t know.

Dr. Thomas Flaig:

Both of those things are true. We’ve made great progress and it’s not nearly enough.

Rick Bangs:

Right. So now how long have you been working on NCCN guidelines?

Dr. Thomas Flaig:

Rick, you’re going to make me look at my CV or something. I think I’ve been chair for over five years and been involved in the guidelines, so it might be close to ten years in total actually. I’ve had the pleasure of working with these guidelines for a long period of time, and it really has been a pleasure.

Rick Bangs:

Looking back on those five or ten years, what do you think of the most significant changes in the guidelines have been?

Dr. Thomas Flaig:

I think when the immune checkpoint inhibitors appeared right five or six years ago now, maybe slightly longer, to me, it ushered in something different. Many of us have been working on developing new therapies for bladder cancer. We had trouble getting traction, and I think when we suddenly had trials reporting that showed efficacy and FDA approvals, we said, we can design trials, we can complete them in bladder cancer, improve therapy. There is a shift in our mindset.

And also the way that academic people interacted with pharmaceutical people to say, yes, we can design trials together. We can complete these and we can answer questions for our patients. There was that shift, and now it’s just taken off and we’ve continued to prove a lot of drugs. But if you remember ten years ago, that was not the mindset.

Rick Bangs:

No.

Dr. Thomas Flaig:

The pharmaceutical companies had these drugs coming out in different areas, but they weren’t necessarily looking at them in bladder cancer. And that’s really been, I think, the most significant change I’ve seen. This idea that we can do these things together and I should bring in patient advocates, patient engagement, people willing to go on these trials and do these things because that’s [inaudible 00:25:39] needle forward for the whole group.

Rick Bangs:

Yeah. It’s been so rewarding to watch this. Okay. So now you mentioned early on you talked about geographic consideration. So I want to spend a little time talking about that. So we’ve got local healthcare systems for a country, for example, there’s government oversight. So I think in some countries, they use the US guidelines, they use FDA approval, or they use US guidelines, and that kind of drives their strategy, their own local guidelines. But in other countries, that’s not the case. And I know you’ve done some work in Rwanda and Ghana relative to applying the NCCN guidelines, which I think would reveal some important considerations in applying guidelines. So can you talk about that experience?

Dr. Thomas Flaig:

Happy to do it, and it’s been a great pleasure and a joy to be able to join the NCCN on what we call the harmonized guideline development. I’ve been particularly involved in Sub-Saharan Africa. I believe there’s also an effort to do this in the Caribbean and other geographical areas. I’ve been both to the Ghana conference and then the Ethiopian Conference. I’m leaving for Rwanda shortly, maybe at the time this post up, it’s underway.

Yeah, it’s really something to think about, right? Because there’s different aspects to it. You have to think about resource level differences geographically. And I think a variety of guidelines have tried to think through this. But then you also have to think about, there’s other cultural geographic considerations that go into that.

So the idea behind the harmonized guidelines, you take what we call the parent guideline, the one we’ve developed in the United States. You then get a group of experts in the field. So again, this particular work has been in conjunction with the African Cancer Coalition and others. So it’s largely driven, the vast majority of people developing the guidelines are African oncologists, surgical specialists, radiation oncologists. You take certain parts of the guidelines and you gray them out. You don’t remove them completely, but you gray them out so the text is a different color. You add in different things. So it might be that an MRI is not appropriate in certain settings. That text is lighter gray font, but an X-ray would be appropriate in that setting. It’s available, it’s used. And so a blue text with x-ray would be put in there. And there’s whole discussion then again about this local context and how things are going. I might say it’s one of the more rewarding things that I’ve been able to do with the NCCN, with guidelines and oncology in general, and I’ve greatly appreciated my involvement in that.

Rick Bangs:

So the driver for graying out something like MRI would be things like, there isn’t a lot of MRI equipment or something is so expensive that they can’t manage it within the budget they have for the country’s healthcare. Those are kind of the things that get factored in here.

Dr. Thomas Flaig:

Yeah. So it doesn’t make any sense to have a guideline that’s listing out, let’s say, diagnostic endeavors like we’re saying here for MRIs, if it’s not available. So if it’s not readily available in that resource level, it’s not helpful. But then what do you do? Do you skip it all together? Do you do an x-ray? Is that useful in that situation? Do you use ultrasound? Ultrasound is fairly widely available. It might be a good backup, and it’s a reminder that there’s a consensus that we don’t do MRI, for example, but ultrasound for that body area is a good substitute that’s readily available. Or for example, x-ray is a good substitute for that particular question.

Rick Bangs:

Okay, great. All right. So any final thoughts?

Dr. Thomas Flaig:

Well, Rick has been a little nostalgic talking about this and thinking about it. I have to say, in the busy world we live in, you sort of go from what’s new, what do we have to address, and so forth. It’s interesting to stop and think back to the last five or ten years of how we’ve thought about bladder cancer care and how the guidelines have reflected that.

I think as we look back, it’s been a remarkable time. We’ve seen people come together. And I think maybe that’s where I’ll leave things that we’ve seen academic people who have dedicated their career focus to bladder cancer. We’ve seen pharmaceutical companies that have said, “We want to test our drugs in this setting to see if they can have impact.” And most importantly, we’ve seen patients and support members and family members who have said, “We want these trials to be done in bladder cancer. We want to find better therapies, and we’re willing to participate and support these things.” And if we think back to ten years ago, we were in such a different place than we are now. And I think despite, again, making progress, we haven’t done enough, but we have momentum now, I believe, to see a real difference going forward.

Rick Bangs:

Absolutely. Absolutely. And it’s exciting area for people who are starting their careers in cancer. Bladder cancer is an exciting area, and years ago it was less so. Dr. Flaig, I want to thank you for helping us understand the importance of guidelines in managing bladder cancer and the process and challenges generating and interpreting those guidelines.

Dr. Thomas Flaig:

Mr. Bangs, it has been a true pleasure, as always.

Rick Bangs:

All right. If you’d like more information on bladder cancer, please visit the BCAN website, www.bcan.org. Dr. Flaig, in case people wanted to get in touch with you, could you share a Twitter handle or other information that you would like people to have?

Dr. Thomas Flaig:

Well, Rick, I’m actually on Twitter, which is something just for the last year or so. So TomFlaig, F as in Frank, L-A-I-G, TomFlaigMD is where I’m at Twitter, so you could certainly follow there and see a little bit what we’re doing here at the University of Colorado and also in bladder cancer.

Rick Bangs:

Excellent. Just a reminder, if you would 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 like this podcast, never miss an episode by clicking on the subscribe button on your favorite podcasting platform. Thank you for listening, and we’ll be back soon with another interesting episode of Bladder Cancer Matters. Thanks again, Dr. Flaig.

Dr. Thomas Flaig:

It is my pleasure.

Voice over:

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