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Ashish Kamat: Hello everybody, and welcome to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat, urological oncologist from Houston, Texas, and it's a pleasure to welcome to the forum once again, Tullika Garg, who's joining us from Geisinger Health System. Welcome, Tullika.
Tullika Garg: Thank you. Thank you so much for the invitation.

Ashish Kamat: So at the recently concluded think tank that was held, there were lots of interesting topics, but I think one of them that was extremely, extremely timely and very much relevant to our aging bladder cancer patient population is how do you optimize bladder cancer care for older adults, right? As you obviously know, and for the reader's benefit, there's a lot of older patients who don't get any care at all. Then there's a lot of older patients who get suboptimal care simply because people assign them a numeric age, right? I mean 80, 85, 90, not looking at physiology per se. So I'm really interested to hear what you and your group have to share with our audience on what you guys discussed at the think tank on tailoring the complicated treatment for bladder cancer with the complicated health needs of our older patients.

Tullika Garg: Yeah, absolutely. Thank you. Yeah, I just wanted to open by sharing the slide with all of the wonderful people that I was on this panel with. Dr. Guercio from University of Rochester organized our team. And we took a bladder cancer continuum approach with our panel where each of us highlighted different aspects of care for older adults across the spectrum of stage. So I talked about non-muscle invasive bladder cancer. We had a wonderful medical oncologist, Dr. Kadambi from University of Rochester, who talked about muscle invasive disease. Dr. Kessler from University of Colorado talked about more advanced disease and the metastatic setting. And then Dr. Rabow from UCSF talked about the role of palliative care in this population. So as you mentioned, we are going to see a rising incidence of bladder cancer in older adults. All baby boomers will be over 65 by 2030. And these are some predictions from SEER showing that the incidence of bladder cancer is going to increase by 68% by 2030 in older adults.

And bladder cancer has the highest median age at diagnosis of all cancer sites, 73 years. And the peak of diagnosis is in the eighth decade of life. And about 75% of the cases are non-muscle invasive. So I'll talk a little bit about non-muscle invasive disease to start. We know that it is a very burdensome chronic condition in our older adults. It has a very high recurrence rate from 30 to 70% depending on their risk category. And so as a result, these patients need to undergo frequent cystoscopy and intravesical therapies, and they also have to undergo frequent ambulatory surgery under general anesthesia for the recurrences. And I always think about TURBT as a so-called low-risk surgery that is done in high-risk people. And so when we look at our guidelines from the AUA and the SUO for surveillance and for intravesical therapy, we can see that the total visits really accumulate for this population. So the burden is really enormous.

And so we also have learned from our prior research that bladder cancer patients tend to manage a lot of other coexisting chronic conditions. In our health system, it's a median of eight coexisting chronic conditions. We also know that while treatment for non-muscle invasive bladder cancer does reduce the risk of death, we also know that there are competing risks from these other chronic conditions which are associated with an increase in death, which outweigh the treatment benefit. And then in surveillance schedules, when we look at what is gained from continuing intensive surveillance in our older adults, it's not a lot in terms of additional quality adjusted life years. So what this all means is that we need to tailor care by identifying what matters most to our older adults. And because of the chronicity of non-muscle invasive bladder cancer, that can change over time.

So I'm just going to transition over to muscle invasive bladder cancer. So in muscle invasive disease, a lot of times what we're thinking about is neoadjuvant chemotherapy and we're thinking about major surgery like radical cystectomy to remove the bladder. And we're trying to make decisions about who's a candidate for those types of therapies. And so one of the mainstays of assessment is, as you mentioned earlier, thinking about physiologic age versus chronological age because we don't want to under treat people who are fit and could really get all the benefit from both neoadjuvant chemotherapy and radical cystectomy, but we don't want to over treat people who may not benefit from the full court press. And so one way that we can try to figure out how to make these decisions is by assessing different geriatric conditions in our patients using geriatric assessment. And there's some really interesting data that was discussed specifically this clinical trial, cluster-randomized trial, the GAP70+, which looked at how geriatric assessment could inform treatment decisions in the chemotherapy setting.

So for this study, they enrolled older adults who were 70 or older with incurable solid tumors or lymphoma, and who had at least one geriatric assessment impairment that was identified. Their medical oncologists were randomized to receiving a geriatric assessment summary with management recommendations versus usual care with no geriatric assessment summary. And they found that the patients who received the geriatric assessment summary had a 26% reduction in grade three to five toxicity, fewer falls, and they did have more medication discontinuation because it was known that they were frailer and may not tolerate the therapy, and they had reduced cancer treatment intensity for the same reasons. So we would have really compelling data to help us to tailor treatment decisions and tailor medications in the muscle invasive setting.

As far as advanced bladder cancer, we are realizing that our clinical trials may not be fully representative of our older adults. A lot of trials exclude people with poor performance status. They exclude patients with poor renal function. And a lot of our older adults have so many other things that they're dealing with. Enrollment in a clinical trial may not be feasible for them. And so a lot of our data is based on younger and healthier people. And so it's hard for us to translate those findings into somebody who may be older and frailer. And also for these patients with advanced disease, this is a really interesting study. We need to better understand how we can align treatment decisions with what people want and what their goals are and tailor that treatment. So this was an interesting study in which they looked at patients who were being enrolled on clinical trials for chemotherapy for a lot of different malignancies.

And they asked them what do they want? And only 61% wanted to stay alive as long as possible, but 40% wanted to either maintain independence or reduced symptoms. And interestingly, 82% in this study actually wanted to maintain their cognitive function above longevity. So the things that make us human are the things that we make our decisions on. So the last part of our panel focused on palliative care. And I think the most important thing that I learned from this is that hospice is really only one part of palliative care, and it's actually one of the smallest parts of what palliative care can do. So palliative care is specialized for people with serious illnesses. The goal is really to improve quality of life. It's appropriate for anybody at any stage and at any age when they're dealing with a serious illness.

So it's not just for cancer patients, it's also for people with COPD or other chronic illnesses that are in the later stages. And it should be provided together with curative treatment if that is consistent with the patient's goals. And when I talk to my patients about palliative care, I tell them that it's not just about hospice, it's also about trying to help each person live the best day that they can each day. And so symptom management is a big part of this as well. Palliative care is very underutilized in bladder cancer. Nearly half of Medicare patients who are dying of bladder cancer had high intensity care and not palliative care at the end of life. Only 9% of patients with bladder cancer receive palliative care as part of their cancer care. But this is something that patients and caregivers actually want. They want to talk about it and they want it to be a part of their care.

And so even in my clinical practice, more and more, even if I am trying to get somebody through curative intent treatment, I'm engaging them with palliative care to help with pain management, ongoing discussions about goals of care and other symptom management like fatigue. Fatigue is a huge issue with our older bladder cancer patients as well. So just some key take home messages from our panel. Bladder cancer incidence is rising in older adults. Aging influences care and treatment decisions across the bladder cancer continuum from non-muscle invasive bladder cancer to the end of life. I feel like a lot of times we think about just certain pieces of the continuum, but it really affects the entire thing. We need to make bladder cancer decisions within the larger context of a person's life and where they are with their aging process, by considering the tradeoffs that they may need to make, measuring and managing their geriatric conditions, and then of course, maximizing their quality of life. Palliative has a role across bladder cancer continuum and we should engage them early and often. So thank you again for the opportunity to talk about this.

Ashish Kamat: Thanks so much, Dr. Garg. I mean, a lot of what you mentioned is it's almost like aha moments, right? But at the same time, it's unfortunate that these are aha moments, because it all makes sense that when we're dealing with patient populations, we talk about pediatrics, we talk about female, male, geriatrics is a whole different sort of being state of our patients, right? And I think it's amazing that if you just have geriatric assessment, you can reduce your toxicity by 25%. It's just like the recent data that's coming out showing exercise improves survival in colorectal cancer. I mean, it's such obviously simple things to do, but sometimes things that are simple are the hardest. So let me put you on the spot. And could you summarize your and your panel's sort of recommendations for people that are listening in that are taking care of older patients in the bladder cancer arena? What are your top three, four or five nuggets or pieces of advice or something that people could use in the clinic today?

Tullika Garg: So number one, I think, is to use some form of a frailty screener in your clinic. And it could be something as simple as watching somebody walk down the hallway. I mean, it doesn't have to be a full on two hour geriatric assessment. There are also very quick patient reported tools where somebody can just fill it out in the waiting room, but use something like that to guide your decision making and to try to understand the larger context that the patient is living in. I think the second thing that really came up, I think, and was a common theme throughout all of our presentations was understanding what matters most to our patients.

And having those conversations to understand what their goals and preferences are. And I think that goes across the continuum because it's not always cut and dry. And I think it's easier to have some of these conversations around treatments when we understand what it is that somebody's looking forward to. Are they trying to get to a grandkid's graduation or wedding? Are they most concerned about being able to stay home and be able to take care of their spouse who may have dementia? So hearing their stories and really understanding what matters most for our patients is really key. So I think it's getting at those geriatric conditions and then getting at what matters most. It's the science and the art of medicine.

Ashish Kamat: And I think patient-centric care is something that we all do. It's just something that we have to recognize has to fit in within certain parameters, right? And one of the things that we have launched through our International Body Cancer Group and UroToday and the think tank is essentially getting people to think more about everything that we do is for the patient, obviously. But it's very important to take into consideration not just the patient's requirements and needs, but also the requirements and needs of their caregivers.

Especially the older patients, some of our older patients can't have their grandson or granddaughter take that time off to bring him to the hospital every week for six weeks. So you can't really recommend a weekly treatment. We got to recommend something that's less frequent. And similarly for radical cystectomy, which is on the other spectrum. Can we do that? Should we think about tri-modal therapy in the context of older patients? There's so much to unpack from this panel discussion that you have, Tullika. Really looking forward to seeing what you guys do during the year. And hopefully you'll be back again at the think tank next year, and we can have you here to update us on what's going on.

Tullika Garg: Absolutely. Thank you.

Ashish Kamat: Take care. Thanks.

Tullika Garg: Thanks, you too.