Transcript of “What You Need to Know About Smoking and Bladder Cancer with Dr. Richard Matulewicz”

November 17, 2021

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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 B-C-A-N.O-R-G.

Rick Bangs:

Hi, I’m Rick Bangs, the host of a Bladder Cancer Matters, a podcast for by and about the bladder cancer community. I am 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. The podcast is sponsored by Merck and Bristol Myers Squibb.

I’m excited to have Rich Matulewicz, a urologic oncologist and an assistant professor at Memorial Sloan Kettering cancer center department of surgery. And Weill Cornell medical college. Dr. Matulewicz is a surgeon and implementation scientist whose primary research is his improving care delivery in urologic oncology. He’s also a recipient of a Bladder Cancer Advocacy Network or BCAN John quality fellowship award, and a recent recipient of the American Urological Association research scholar award. Dr. Matulewicz, I am so pleased to have you on our podcast and especially pleased because today is designated the Great American Smokeout. And we are going to talk about that very subject, smoking cessation with a focus on the bladder cancer context.

Dr. Richard Matulewicz:

Thank you so much. It’s an absolute pleasure to be here, to talk about something near and dear to my heart, and certainly something very impactful in the bladder cancer community. I definitely want to thank you all for the invite, and I’m very excited to talk about this topic today.

Rick Bangs:

As are we, so let’s talk about smoking in 2021. Who is smoking?

Dr. Richard Matulewicz:

Yeah, so there’s some good and recent data on who is smoking in the United States. And this is coming from the Surgeon General’s report, which is not often released, but we were fortunate enough to get one in January of 2020, which highlighted the current state of tobacco use with a focus on smoking in the United States and currently about 14% of US adults smoke. And the great news about that is that, that is the lowest number in US history since data started being recorded in the mid 60s. And at the current time, about 20% of the current population can proudly report that they are former smokers.

Dr. Richard Matulewicz:

And to put this more into perspective, in 1965, when this data started being collected, 50% of men and roughly a third of women smoked cigarettes daily. So, this is a dramatic increase and certainly a step in the right direction. And while this is true that these declines are seen among all ages, races, genders, there are some concerning upticks in tobacco exposure among youths, mostly driven by vaping. And I know we’ll get around to talking to that more, but all in all, this is incredibly encouraging news that less and less people are smoking than ever before.

Rick Bangs:

Yeah. Those numbers in 1965 are really eye opening.

Dr. Richard Matulewicz:

Staggering.

Rick Bangs:

Yeah. So, what cancers are linked to smoking?

Dr. Richard Matulewicz:

So, even beyond cancer, pretty much if you name it, smoking can either cause it or make it worse. But specifically within cancers, obviously the heavy hitters, lung, head and neck cancer, and then you start to have to consider other cancers like stomach, liver, pancreas, colon and rectum, and then certainly the cancers in the urology world, bladder and kidney cancer. Urologically, I think it bears or it’s worth mentioning that erectile dysfunction, worsening fertility and irritated voiding can also be caused and are linked to smoking. So, this is something that affects people who smoke pretty much from head to toe and can certainly make existing issues even worse.

Rick Bangs:

How does the probability of getting cancer vary between smokers and non-smokers?

Dr. Richard Matulewicz:

Yes. So, this is something that does have a bit of a variety when it comes to specific types of cancers. So, we know that outside of lung cancer, that bladder cancer, which is obviously the focus of the podcast here today, has one of the highest population attributable risks of smoking. That is about 50% of people that have bladder cancer have gotten it because of cigarette exposure and tobacco exposure. Within some of the other urologic cancers, odds are anywhere from three to five times higher to get cancer compared to people who are never smokers and certainly higher than people who are former smokers, but not to that extent.

Dr. Richard Matulewicz:

And the concerning part about this is that actually some of these are exposures and some of the odds of developing cancers amongst smokers seem to be getting worse. And this is thought to be due to the cigarette content changing over time. And although there’s less tar in cigarettes and the overall prevalence of smoking is less than ever before, there are now higher concentrations of certain bladder cancer specific carcinogens that are found in cigarettes today than in prior years. So, this only seems to be getting worse and much of this is also related to the intensity and the duration of exposure over time. So, the more you smoke, the more you are at risk.

Rick Bangs:

So, this is news to me that the bladder cancer causing agents are, there’s more of them in cigarettes today.

Dr. Richard Matulewicz:

Yeah. And the exact reasons for that are not necessarily clear. There’s a lot of environmental science studies that are pursuing the reasons for this, but the thought is that the tobacco content has changed over time. And we’re seeing more nitrosamines, aromatic amines, and polycyclic aromatic hydrocarbons, and these are all markers of exposure and certainly carcinogens that are found even more so now than ever.

Rick Bangs:

Wow. Okay. So, you touched on this a little bit, but I want to talk about young people. So, what are the trends in adolescents in young adults?

Dr. Richard Matulewicz:

So, although smoking has declined among youths and young adults, there has been a concerning uptick in tobacco exposure by way of vaping and Juuling and all of the sort of e-cigarette and heat, not burn products that have become almost ubiquitous in youth culture. And although these are not as well studied as cigarettes and other tobacco products, there are some concerning findings that we can touch on a little bit later, some work that we’ve done with colleagues at UNC that do demonstrate that although these products are not necessarily combustible cigarettes and don’t necessarily have the same type of exposure, there are the presence of these carcinogens and markers of exposure found in the urine. And certainly therefore in the general systems of the youth that are smoking them or using them.

Rick Bangs:

Okay. So, from a vaping perspective, is it safe, safer, or we just don’t know yet?

Dr. Richard Matulewicz:

I would say that you can probably say that it’s safer, and these are actually being used in some research studies and in general, in caring for patients with tobacco addiction and tobacco use as a means of harm reduction. So, I think if you can replace cigarette smoking with a vape or with a heat, not burn product, chances are your exposures are going to go down, but we’re not really sure what the exact threshold is of these exposures that does portend a higher risk for cancer and carcinogenesis. So, I would say, avoid saying that these are safe, but I can say with reasonable certainty that they’re probably safer. I think the long term consequences are certainly not well known. This is something that our group is also pursuing. And the reality is that a lot of people who use these devices are also current cigarette smokers. And this has been some of the difficulty in studying these products in isolation and their true risk is that there’s several dual users and users of other tobacco products in addition to the e-cigarettes.

Rick Bangs:

Okay. That makes sense. All right. So, let’s talk about some other forms of smoking. Sometimes I think people believe cigars and pipes and marijuana, because they’re not cigarettes, they are safer. So, are they different, less risky?

Dr. Richard Matulewicz:

Yeah, so I would not say safer, because actually a lot of these products have their own unique exposures. Certainly whether you inhale a pipe or a cigar will contribute to how different or how similar your exposure is to traditional cigarette smoking, but for people who are just smoking cigars in the traditional sense, without inhaling, there are larger concerns and risks about mouth cancer and other oral cancers, just based on those exposures. So, your lung cancer risk may not be as much as traditional combustible cigarette users, but you do have a kind of different risk of developing cancers and other oral issues.

Rick Bangs:

All right. And lots of folks have been exposed to secondhand smoke. So, is that different? I think I read that people who’ve been exposed to secondhand smoke have kind of a different cancer profile than those who have smoked directly.

Dr. Richard Matulewicz:

Yeah. This is another thing that’s a bit difficult to study, but I think there’s emerging evidence that any sort of exposure to tobacco smoke can be harmful to your health. And certainly the biggest issue here is similar to the smoker themselves is the intensity and duration of the risk. So, if you lived with someone who was a very heavy smoker, two packs a day, and you were perpetually around them in a poorly ventilated room, I would say that your risk is certainly higher than someone who was simply at a bar or a bowling alley or something with some transient exposure. This is an area of research interest, for sure. And I think that we can say that some of the public health measures that have led to reduction in indoor and airline related exposures are also certainly a step in the right direction and probably a benefit to the general public’s health.

Rick Bangs:

So, let’s go back to the direct linkage between smoking and bladder cancer. And I think you said something like 50% of bladder cancer survivors have smoked. Is that right?

Dr. Richard Matulewicz:

Yeah, that’s pretty much correct.

Rick Bangs:

All right. And so there’s different types of bladder cancer and what types of bladder cancers might smokers get?

Dr. Richard Matulewicz:

Yeah, so people who are, I think it’s worth discussing, just who least smoking and who are former smokers as well, because this plays into some of the efforts that we have also to get people to quit smoking. And anywhere from 15 to 20% of people diagnosed with bladder cancer are current smokers. And the rest that make up that 50% population attributable risk is pretty much the 30 to 50% of people that were former smokers. So, when you’re talking about tobacco exposure in patients who are diagnosed with bladder cancer, as you can see, the burden of smoking in this group is quite high. And what that causes is pretty much a traditional urothelial carcinoma. So, this is just the more common bladder cancer. This is not necessarily a squamous cell carcinoma, which is generally related to chronic irritation with a catheter or infection or any of the other rarer variant types of bladder cancer. The biggest link is to just urothelial carcinoma of the bladder.

Rick Bangs:

As a smoker, would I be more apt to get low grade or high grade bladder cancer?

Dr. Richard Matulewicz:

Yeah. So, this is something that has been studied and there’s definitely some evidence that the intensity and duration of smoking both leads to increases in the grade and stage at the diagnosis of bladder cancer. So, said another way, people who are heavier smokers tend to present with high grade disease and certainly more advanced disease. And I think the important thing about all of this too, is that not only does this increase your risk of more advanced disease or more aggressive disease, but continued smokers also demonstrate attenuated treatment benefits. So, chemotherapy tends to be less effective, surgery tends to be more higher risk. So, not only are smokers coming in with worse disease, some of their treatment outcomes are still affected by smoking.

Rick Bangs:

All right. So, let’s talk about those treatment options. So, smoking triggers certain mutations, kind of changes in the genes. And so are there treatments today that might work for those with a smoking history, because of the uniqueness around the bladder cancer that would be generated from smoking?

Dr. Richard Matulewicz:

Yeah, that’s a great question. And I think that’s something that we’re going to see a lot more of in the next five, 10 and plus years. So, without getting too deep into the omics and genetics weeds of all things, I think we can say with reasonable confidence that several studies have shown some associations between smoking and really specific mutational signatures in bladder cancer. And this is work that’s been done by a number of people, including colleagues here at Memorial, Eugene Pietzak and Josh Meeks at Northwestern that have really tried to explore what these carcinogens do to generate cancer development, and then using those specific findings as basically a point of leverage for treatment.

Dr. Richard Matulewicz:

So, at the moment, there’s nothing specific from a treatment perspective for those with a smoking history, but we actually have seen almost paradoxical improvements in the efficacy of intravesical chemotherapy in patients who continue to smoke. And this is something that we’re actively exploring and many people are actively exploring to see what the reason for this is, if it’s just an accumulation of damage to the DNA that benefits somewhat paradoxically, or if there’s something else working to drive these findings.

Rick Bangs:

Yes. Okay. So, we’ll be standing by for information at a later time and day.

Dr. Richard Matulewicz:

Absolutely. We’ll have to do another podcast in a few years to give a good update on that.

Rick Bangs:

Okay, good, good, good. And we’re hoping you’re going to have a lot to update us on. That would be awesome.

Dr. Richard Matulewicz:

Me too. Me too.

Rick Bangs:

That would be awesome. Okay. So, if I’m a smoker and I have not been diagnosed with bladder cancers, are there certain actions that might make sense for me that wouldn’t make sense for somebody else who did not smoke?

Dr. Richard Matulewicz:

Well, I think the first thing is to make sure that you stop smoking, of course, but I think the most important thing kind of plays into the whole aspect of awareness. And it’s something I think that BCAN does beautifully as a group and as an advocacy network to really bring attention to bladder cancer and the signs and symptoms of bladder cancer. And you can probably see where I’m going with this. But I think that the more people that are aware of some of the early signs of an underlying bladder cancer, the more patients will be empowered and motivated to see their doctor when those show up. And the biggest thing and the most important thing that I think anyone can take away from this is if there’s any sort of blood in the urine, both visible and non-visible and you have a smoking history.

Dr. Richard Matulewicz:

I think you have to take that very seriously. And there are situations where people, especially women, are sort of the significance of blood in the urine is downplayed, because women tend to get urinary tract infections. And this has led to a real delay in presentation for a lot of people, women especially, because these are dismissed as gynecologic bleeding or urinary tract bleeding, men with prostate enlargement tend to have this dismissed. I think anytime you see blood in the urine, it is essential that you contact your doctor and then consider getting an evaluation. And that is even more important for patients who have smoked.

Rick Bangs:

So, it sounds like it’s probably a good idea to have your smoking history discussion with your doctor. And you’re probably more likely to get a cystoscopy if you have been a smoker in the past.

Dr. Richard Matulewicz:

Yeah. And this is actually directly involved in the urology guidelines, both in the United States and abroad that the risk status, and certainly the intensity of the evaluation for blood in the urine is increased in people who have smoking histories and people who have more intense smoking histories. So, this is something that we know increases the risk and makes us really search even more thoroughly than in those who didn’t smoke.

Dr. Richard Matulewicz:

And I think it’s also important to mention that in the era of screening and trying to find cancers before they become more advanced and in a treatable localized fashion, unfortunately there has not been any role for screening for bladder cancer. And this is because it’s a somewhat more rare type of cancer than some of the other cancers we screen for, like colorectal cancer, like lung cancer. But this is certainly an area of research with urinary biomarkers. I know some of the guests you’ve had on in the past are really real leaders in the space of urinary biomarkers for both screening and treatment. And also with microscopic hematuria, which is something that I have devoted a lot of time to studying and trying to figure out the best means of evaluating patients that have microscopic hematuria, which is sometimes the only sign of an underlying bladder cancer. So, I think that’s another good thing for patients to be aware of.

Rick Bangs:

Yeah. I think it’s helpful to know kind of your risks that you can help manage them with your doctors.

Dr. Richard Matulewicz:

Absolutely. I mean, the best advocate for yourself is yourself. So, it’s definitely important to really understand your body and be honest with yourself and with your doctors about where your health is at.

Rick Bangs:

Absolutely. Absolutely. Okay. So, once I’ve been diagnosed, and then I know that I have bladder cancer, what’s the impact of continuing to smoke during and after treatment. And I want to split the during versus the after. And I think you kind of hinted at this before. Any implications on the efficacy of the chemo or the immunotherapy or whatever treatment I’m getting.

Dr. Richard Matulewicz:

Yeah. And I know I’m going to sound like a broken record by the end of this podcast, but there’s no better time to quit smoking than at the time of diagnosis. We never want to blame or focus on the past in these types of situations. But I think the important thing to really recognize is to look forward and really understand that smoking is an integral component of your cancer treatment. And that is for all of these reasons that I’m about to mention, to answer your question directly. Continuing smoking after bladder cancer diagnosis will affect pretty much every aspect of treatment. There’s some evidence that there’s an increased risk of recurrence in patients who have non muscle invasive bladder cancer. There certainly tons of evidence to suggest that the perioperative time period, so that’s before, after, during procedures are much, much higher risk for patients who smoke.

Dr. Richard Matulewicz:

And that’s simply because of the cardiopulmonary side effects of smoking. It increases your risk of heart attack and stroke at the time of surgery, certainly COPD as a comorbidity, along with bladder cancer makes you higher risk for undergoing pretty much any surgical procedure. So, that in and of itself is an issue, because most patients who are diagnosed with bladder cancer undergo at least two or three procedures early on in their treatment. And some of those are, are certainly larger procedures like a radical cystectomy that, that fitness and the heart and lungs is absolutely critical.

Dr. Richard Matulewicz:

Continued smoking after diagnosis when patients are given neoadjuvant chemotherapy, certainly attenuate the treatment response. And this is work that USC’s group has really demonstrated nicely. And I thought they were actually very nicely put the cigarettes in their figures at that time. So, that’s definitely a paper worth reading. I’m not sure exactly what the effect among patients who are undergoing immunotherapy is just yet, but this is certainly something that needs to be explored as well. And all of this kind of comes together in the fact that the urology community certainly needs to begin to recognize the importance of collecting a lot of this information and using it as a potential interaction and something that really affects treatment from beginning to end.

Rick Bangs:

Okay. So, it’s never too late to quit smoking. That’s going to be one of our themes and very appropriate because the day we’re releasing this podcast is the day of the Great American Smokeout. All right. So, let’s talk about smoking cessation. And over the past few years, I think there’ve probably been some advances in smoking cessation. So, what are my options for smoking cessation in 2021?

Dr. Richard Matulewicz:

Yeah, I think the advances are kind of the understanding first and foremost, that everyone is different and that what works for one person may not necessarily work for another. I think the use of information technology and mobile technology has helped, because really what we do know is that the evidence-based treatment for smoking and therefore the best way of quitting smoking includes a combination of pharmacotherapy and behavioral counseling. And the behavioral counseling and strategies. That’s really where some of these novel approaches like phone apps, counseling through telehealth, and certainly quit lines that are now ubiquitous in every single state in the country, that really help patients quit smoking by supporting them emotionally, behaviorally, reducing some of the triggers and other fixations associated with smoking.

Dr. Richard Matulewicz:

Now, going back to pharmacotherapy, the best way of approaching smoking cessation with pharmacotherapy usually includes some sort of short term nicotine replacement over the course of weeks to months and also consideration of prescription drugs. And these two things together usually will have the patient achieve the greatest chance for success. And that’s because they work on a few different mechanisms, including the short term physiologic need to nicotine, and then slowly weaning off of that. And then some of the other psychologic side effects of tobacco addiction.

Rick Bangs:

So, we’ve got technology helping us. We’ve got people helping us, we’ve got pharmaceuticals helping us, and there’s probably some other things helping us. And a lot of this is pretty much really improved in the last several years.

Dr. Richard Matulewicz:

Yeah. I mean, the FDA has, I think it’s seven or eight, different medications now that are approved specifically for smoking cessation. So, there is a lot of support. And I think the most important thing is really understanding that this needs to be approached as a chronic medical problem and not something that is going to just completely and totally get better overnight and really tackling the problem as if it’s something that is not just going to be improved with the snap of fingers.

Rick Bangs:

Right. Right. And we’ve got telehealth, which, I mean, that has to be a help, because just the logistics of getting there and making the appointments and all that on the counseling side got to be difficult. So, that’s hopefully improving.

Dr. Richard Matulewicz:

Yeah, absolutely. I think getting people in front of experts is incredibly important and telehealth and so some of the other mobile platforms have really made that easy and it certainly improves access in some ways too, where you don’t necessarily need to be in close proximity to a big medical center to get this care. You can get it from your couch in more rural settings. And certainly in places that wouldn’t have normal access.

Rick Bangs:

Right. Right. And I don’t have to take on the commute on top of the time to get the counseling. Yeah.

Dr. Richard Matulewicz:

It’s always a big treatment burden for, especially for patients undergoing treatment for other things other than just smoking.

Rick Bangs:

Oh, yeah. What side effects might they experience and can they too be treated?

Dr. Richard Matulewicz:

Yeah. So, the side effects are, they’re connected to this specific drugs and some of the prescription drugs may have slightly more worrisome side effect profiles, but for the most part, what patients experience there is usually just some nausea and a little bit of potential restlessness, very infrequently there are some psychiatric issues that come along with these and the medications should generally not be given to people with seizure disorders or any other concerning mental health issues. And this is why those prescription drugs remain prescription drugs, really because they need to be administered and certainly monitored by a health professional. As far as the side effects of the nicotine products. For the most part, these are very tolerated and actually patients will experience some improvement in some of the side effects associated with nicotine withdrawal. So, for the most part, as long as these are used appropriately, they’re fairly well tolerated.

Rick Bangs:

So, I’m a little curious about weight gain, because I know lots of people have, I mean I’ve seen lots of discussion about that over the years. Is that as a “side effect”, because I’m sure there’s a lot of factors involved in that, including having a better sense of taste and all. Is that something that is addressed today?

Dr. Richard Matulewicz:

Yeah. I mean that is certainly, that’s a great point. And that’s certainly something that people worry about when they do quit smoking. And that is sometimes inherent simply to quitting smoking itself and not necessarily just the medications. The cigarettes in the nicotine are an appetite suppressant. So, it is something that people do experience in the short term, usually after, when initiating this whole process. The good news is, and the way a lot of behavioral counseling and certainly tobacco treatment plans is that this is not necessarily something that is treated in a silo. Usually smoking cessation is bundled with other lifestyle interventions, improving exercise, even if it’s just going for short walks, more moderation with alcohol, simply because smoking a lot of times is not only triggered by some of these activities, but they go kind of hand in hand.

Dr. Richard Matulewicz:

So, the way we like to kind of couch it is that especially around the time of surgery is that you’re you’re training for a big event. And doing all of these things is preparing you as best as possible to undergo and succeed during that event. So, we really like to bundle these and get people out and moving, we call it almost like prehab, where instead of being reactive, we are proactive trying to really improve someone’s general fitness to fight this cancer and undergo the treatment that they need.

Rick Bangs:

Yeah. This prehab thing is a relatively new phenomenon and one that has some interesting possibilities.

Dr. Richard Matulewicz:

Yeah, definitely.

Rick Bangs:

Glad to hear about that. So, if I’ve committed to smoking cessation, who’s going to oversee my smoking cessation medically and how are they trained? How frequently am I visiting them? How does that work?

Dr. Richard Matulewicz:

Yeah. So, there are tons of ways to go about approaching this. And this is really where the personal decision comes into play, because some patients and some people, they really enjoy the group component of this. It’s almost like an alcoholics anonymous where they appreciate the comradery and the support. They like going to support groups and speaking with people and getting tips and tricks on how to avoid these things and really feeling that comradery and that support. And there are other people who are the exact opposite, that they want to do this on their own. They’re not as comfortable sharing these types of things with strangers or even family members or their healthcare providers. So, that’s pretty much the full range of possibilities. As far as the behavioral counseling goes, there are tons of different ways to do this even independent of a healthcare professional.

Dr. Richard Matulewicz:

I think the apps are a great type of virtual support. There’s ways of personalizing your quit plan with the 1-800-QUIT-NOW and the quit apps through the CDC. And a lot of these actually come along with free delivery of nicotine replacement therapy and then sessions where you can even get some prescription medication sent to you after a brief consultation. So, to answer your question directly, your original question, anyone can really, in the medical community, can really oversee this, or it can be self-directed. And one of my big goals is to really improve the way urologists approach this. And I think urologists have a great relationship with their patients.

Dr. Richard Matulewicz:

I think that they’re trusted healthcare providers and that we as urologists can really be levers for behavior change. And my goal would be to have the urologists initiate the smoking cessation pathway, really educate the patient and motivate them to quit smoking by describing to the patient how important it is and all the things that I had mentioned previously about how this is really a part of their cancer treatment plan and how really their long term outcomes can be influenced with this smoking cessation.

Dr. Richard Matulewicz:

And then from there, it’s really relying on expertise and colleagues that do this all often, and then depending on what the patient wants to seek out, dedicated smoking cessation counselors, licensed social workers, certainly psychiatrists. There are a number of different avenues to go down, but really the first step is acknowledging and really wanting to quit and pursuing one of these avenues.

Rick Bangs:

So, might my medical oncologist participate in this? Might they be, and for some patients, would they be the one to start this process and work with a patient? Or is that, in the bladder cancer space, mostly the domain of the urologist?

Dr. Richard Matulewicz:

Well, I think anyone can really, and I think a lot of this is also based on your physician’s comfort with initiating this and familiarity with some of these medications and certainly their training and expertise in behavioral counseling. And to be frank, it’s not something certainly in the surgical world that we’re taught very often. So, it’s something that really needs to be reinforced from our societies, our continuing medical education, and certainly needs to just be recognized a bit more by the community, the urology community, as something that we can really deliver an impact with.

Rick Bangs:

And would you coordinate with a primary care physician? Would they play a role here?

Dr. Richard Matulewicz:

Yeah, absolutely. I think that there’s no more valuable member of a healthcare team than someone’s primary care physician. These are generally internists that know the patient for a very long time, know the patient very well, have a good established relationship. They’re usually fairly local. So, I truly believe that the beginning and the end of things in patient care is centered around the primary care physician and they play such an important role and are so good at what they do, that they are definitely people that I like to involve.

Rick Bangs:

Yeah. They’re unsung heroes.

Dr. Richard Matulewicz:

Absolutely.

Rick Bangs:

Okay. So, now I think some patients might try to argue that by the time they’ve been diagnosed with bladder cancer, the horse is out of the barn. And so I want to hear what you would tell me as a patient if I said that to you?

Dr. Richard Matulewicz:

Yeah. Well, the first thing I would say is that, that is not necessarily true and that is not necessarily my opinion either. It is backed up by a lot of data. I focus on educating rather than blaming or anything like that. And I think the more you’re able to convince someone of the benefits of the behavior that you’re trying to change or influence, the better of an understanding they’ll have as to why they should quit and how they should quit. So, I really focus on detailing all of those benefits that I mentioned earlier, the safety of surgery. I think that people are usually very worried about undergoing procedures and surgery. And this is a way of really motivating them. I like to use the term prize fight when I’m counseling patients that they’re really preparing for that cystectomy or that TURBT. That’s the goal, that’s the date that’s circled on the calendar and use that as a time and a goal to achieve some of those behaviors that they want to change.

Dr. Richard Matulewicz:

I detail all of the possibilities about worse outcomes and recurrence, less effectiveness of the chemotherapy that we spoke about. And I think the biggest thing is that I tell people that we can give you a lot of chemotherapy, immunotherapy, intravascular therapy, all of surgery, but truly the thing that has been shown to impact your quality and your length of life outside of all this other treatment is quitting smoking. So, I really try to focus on telling them that you don’t want to go through all of this for naught, because you’re going to continue smoking and continue to affect your health in other ways. So, I tend to focus on education more than anything, and then some people need some time and I think persistence, and again, approaching this as a chronic medical illness from the provider perspective, incredibly important, because again, not everyone is going to just completely flip their behavior overnight. People need time and they need reinforcement and they need education.

Rick Bangs:

Yeah. So, how successful is smoking cessation?

Dr. Richard Matulewicz:

It’s tough. We looked at this specific question specifically among urologic cancers. And part of the issue is that this is a chronic problem. People do tend to relapse. So, some of the metrics we look at are seven day avoidance of cigarettes versus long term smoking cessation. And I would like to say that patients are a lot more successful than what we’ve seen in all of these studies, but that is not necessarily the case. And I think this is for a number of different reasons. The most concerning of which is that patients are not really getting the tools they need to successfully quit smoking.

Dr. Richard Matulewicz:

And that’s where the cancer care team, the urologist, the medical oncologist, and certainly the patient as well. We all need to kind of get together to make sure that patients are aware of the resources that they can use to quit smoking and they have access to them. So, although I can’t report universal success, I think that really, this is something that we’ll see benefit long term benefit of as soon as we start to recognize the best way of going about doing this through evidence-based solutions.

Rick Bangs:

Yeah, I’m a little curious is why is it so hard to quit? Because we know it’s hard. Why is it so hard?

Dr. Richard Matulewicz:

It’s terribly hard. I think that quitting smoking is probably one of the toughest things that patients will go through. And that’s for a number of reasons. I mean, outside of simply the physiologic addiction to nicotine and some of the other, even just behavioral components of smoking. Smoking is a lifestyle for some people, their family and loved one smoke when they go and have a beer and watch sports, they smoke. When they’re doing sort of any trigger activity, it’s usually associated with a cigarette. Same thing with having a meal or something like that. And for a lot of people, their relationship, their 30, 40 year relationship with smoking is longer than most of their personal relationships. So, this is something that people have really integrated into their lives in many different threads. So, it’s really tough to extricate yourself. And I think the family support and certainly changing some of those things that trigger smoking from a lifestyle perspective can really pay dividends in helping get over some of these difficult barriers.

Rick Bangs:

Yeah. So, let’s talk about some of the things that would improve my success with smoking cessation.

Dr. Richard Matulewicz:

Yeah. I think the best way of going about doing this is really to be pragmatic about your approach and really understanding what approach works best for you. So, if you’re not a person that’s going to go to the support groups or do anything like that, then maybe it’s a good idea to seek out one-on-one counseling or using one of the apps that way, it’s a more private means of going about doing this. I think the other absolutely essential part of this is to use some of those evidence based solutions that we know from randomized trials and studies that do help people quit. And that’s the short term nicotine replacement therapies, some of the pharmacotherapies, and then whichever behavioral support pathway that works best for you. I think the other thing that is helpful is to use what’s out there. The government and at the national level, there’s a ton of free resources and free support available.

Dr. Richard Matulewicz:

The 1-800-QUIT-NOW I think is really beautifully set up. You call number, it connects you immediately to someone within your state and the state specific resources. They will set you up with counseling, they’ll call you, they’ll send you text messages to remind you. Little tips and tricks. And then they’ll also start with the pharmacotherapy agents that I had mentioned. I think really developing coping behaviors and changing some of those lifestyle things and simply understanding that this is something that needs to be done alongside all of the other treatment to really make sure that you have a good outcome.

Rick Bangs:

So, I know I’m sure some of our listeners are really interested and quitting tobacco, and I’ve heard about something that’s called the five A’s and I believe you and other doctors use this to discuss smoking cessation with your patients.

Dr. Richard Matulewicz:

Yeah, we definitely do. I think this is something that I started implementing in my practice in the last few years really as mnemonic and as a framework for making sure I’m doing things correctly from start to finish. And it really reminds you and prompts the patient and you at the visit to go through each of the kind of critical components of considering smoking cessation and starting a patient on that pathway.

Rick Bangs:

Okay. So, what are those critical components? There’s got to be five A’s. So, the first thing that starts with an A is …

Dr. Richard Matulewicz:

That’s ask. And this is something that I absolutely rail upon. And it’s something that we’ve studied at the population level. This is something that urologists are actually very good at and other doctors are very good at, and that’s simply asking patients if they smoke. That should usually trigger a cascade of additional questions that explore the duration of use, intensity of use. Certainly if someone has previously smoked, figuring out if they quit yesterday or they quit 20 years ago. It’s really the way of starting the conversation and certainly the most critical step in my opinion.

Rick Bangs:

Okay. So, you’re going to start by asking me, so then what, what’s the second A going to be?

Dr. Richard Matulewicz:

Second one is going to be to advise. And this is where all that counseling really starts. And this is where I tend to say, look the patient in the eye and let them know that I strongly recommend that they quit smoking. And then that’s where I really start to give my spiel about why and how beneficial all of that is.

Rick Bangs:

So, you’ve asked me, you’ve given me some advice and then where do you go?

Dr. Richard Matulewicz:

So, in patients who are coming back, this is usually where the assess, the third A, comes in. And this is kind of just a circling back to that first A to just figure out where people are at. Some patients will say, okay, well on the next visit, we’re going to do this, that, or the other thing. This is really where you kind of set goals and figure out where the person’s at, you meet them where they’re at, and then you develop the next steps and the plan, which are usually those next two A’s

Rick Bangs:

Okay. So, you’ve asked me, you’ve advised me, you’ve assessed me. And now what are you going to do with the fourth A?

Dr. Richard Matulewicz:

Help, no it’s assist. So, this is really where some of those evidence based solutions come in. And this is where you can begin the process of linking someone up with a counselor, directing them to the 1-800-QUIT-NOW. I’ve left the room and opened up the CDC website that takes the patient through downloading the app onto their iPhone or Android device. So, this is really where you say, okay, well, you’re not leaving this room until we figure out a good plan for you. And here’s what I can offer. You let me know how I can help you with this. And I don’t lock anyone in the room though. I promise.

Rick Bangs:

All right. Okay. So, you’ve asked, you’ve advised, you’ve assessed, you’ve assisted and the last A is …

Dr. Richard Matulewicz:

Arrange. So, this is simply the follow through, in my opinion. This is calling the patient up, checking in, really reinforcing some of the stuff that you’ve discussed with them, making sure that they’ve gotten those medications that you’ve prescribed them or that are coming in the mail. Asking okay, well, when are you going to see that behavioral counselor? When are you going to see the social worker to discuss some of those things? And this is really where the loop I believe is closed. And this is where some of the staff that we have here, and certainly in our smoking cessation clinic are really wonderful, because I think this is a good time point usually a week or so after the visit that you can reinforce a lot of those things and really reinvigorate the patient after the visit to proceed with what you’ve discussed in the office.

Rick Bangs:

Okay. Good. All right. So, now let’s talk about a different scenario. This is a different patient, and this is somebody who’s unwilling to quit tobacco. So, the first patient we were talking and walking through, that’s somebody that was willing, this is somebody who’s unwilling. What would you say to me if I was that patient?

Dr. Richard Matulewicz:

Yeah. So, there are certainly tons of other frameworks and ways of going about approaching this. I generally just continue the education. I think that it’s not necessarily something you can force someone into, but really just keeping the pressure on a little bit, but not in a pushy way. In the past people have used the five Rs, which are somewhat similar to the five A’s, but this is really kind of the next step in assessing why the patient’s unwilling, really reinforcing the importance or the relevance to their disease that you’re helping manage, especially as the urologist. Again, highlighting some of the risks that, that second R of continued smoking, reinforcing the rewards, that third R, and that kind of plays back into the benefits and the relevance. And then from the implementation scientist in me, it’s assessing some of these roadblocks and looking at the barriers, that’s the fourth R, the roadblocks, in and why patients are unwilling to smoke.

Dr. Richard Matulewicz:

And a lot of times this is because their spouse smokes, or they play softball with the guys and they’re out smoking cigars every week. And that would be something that would change their social life, or it’s really trying to figure out where can I intervene at maybe the next visit to help reduce some of these barriers of these roadblocks. And then the last one is, the last R is repetition, and this is just keeping at it and approaching it as that chronic medical problem. That’s really how I like to frame it, but that’s generally my approach.

Rick Bangs:

Excellent. All right. Now, last but not least, I’m sure there are some family and caregivers who are listening and we have to acknowledge they play an important role here. So, the family dynamic can sometimes be counterproductive. So, what guidance do you provide the family so that they’re really helping and amplifying the good aspects of this?

Dr. Richard Matulewicz:

Yeah, absolutely. My patients are probably also sick of my sports analogies, but I like to kind of frame this as the person going through what they’re going through is not really the only person. You’re truly a team and it’s not only the spouse or the son, the daughter, the mother, the father, or anything like that. But your entire social system is kind of going through this with you. And I really enjoy when family members come to visits. I think four years, six years are always better than two. So, I try to really involve caregivers, family members, certainly children and spouses in this treatment plan. And that includes an assessment of how they can help and suggestions as to really how they can play a role, not only in smoking cessation, but in this person’s care along the entire continuum of care, especially bladder cancer.

Dr. Richard Matulewicz:

This is such an involved disease process and really require so much follow up and so many different aspects and components of treatment that I think really having everyone onboard and on the same team, working towards that common goal is incredibly important. And especially when it comes to smoking cessation, it’s going to be extremely difficult for a patient and to quit smoking if their spouse or their live-in family member or someone continues to smoke. Not only that, that secondhand exposure continues to kind of continue some of those deleterious aspects of tobacco exposure.

Rick Bangs:

And who can advise them if they think things are just not going well, it’s not progressing the way it should be?

Dr. Richard Matulewicz:

Yeah. This is where sometimes I get a bit above, it’s above my pay grade. So, this is where I tend to involve our really, our excellent counselors, social workers, folks who really have good expertise in some of these dynamics and some of these other approaches, especially when it’s a close family member or someone within the household. I think that they do an excellent job with all of this. And that’s where I start to offload some of these other approaches.

Rick Bangs:

So, Dr. Matulewicz, thanks so much for your time today and giving us a better understanding of the challenges and opportunities with smoking cessation and the potential upside to quitting smoking as a bladder cancer survivor.

Dr. Richard Matulewicz:

Oh, thank you so much. It was a real pleasure talking about all of this and I hope that this becomes a resource for people and certainly a motivational tool. And I think it’s incredibly important to understand that you can absolutely quit smoking. There’s a ton of stuff to help you quit smoking and outside of yourself and your family, there’s no one that wants you to quit smoking and help you quit smoking more than your urologist, because they understand better than anyone some of the benefits of smoking cessation. And it’s my goal to continue to empower urologists to help patients quit and certainly to empower patients to quit themselves.

Rick Bangs:

And it’s never too late. Right?

Dr. Richard Matulewicz:

Absolutely not.

Rick Bangs:

All right. In case people wanted to get in touch with you, could you share your email or a Twitter handle or any other information you want people to have?

Dr. Richard Matulewicz:

Sure, absolutely. My Twitter handle is @RichMatulewicz, R-I-C-H M-A-T-U-L-E-W-I-C-Z, just my first and last name. And as long as you can deal with some of the quirky music tastes I have and complaining about my New York sports teams, there are some pearls in there about bladder cancer and smoking cessation, but that’s a fair warning. The other thing I absolutely want to, I guess, promote, I have no connection to any of this stuff or conflicts of interest, of course, because these are from the CDC, but the 1-800-QUIT-NOW that I’ve mentioned a couple times is a beautiful resource. And it’s available to everyone in all 50 states. And then actually Quit Start app on the iPhone and Android, which is similarly sponsored by the Centers for Disease Control. I think these are great resources and actually open up a ton of avenues for additional resources and support for smoking cessation. So, definitely want to mention those again and anyone who is even considering smoking cessation should check those out, because I think they will be very powerful help.

Rick Bangs:

And they’re free, right?

Dr. Richard Matulewicz:

Absolutely.

Rick Bangs:

Excellent. The price is right. All right. So, 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. Matulewicz.

Dr. Richard Matulewicz:

Thank you so much.

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 B-C-A-N.O-R-G.