Ashish Kamat: Hello everybody, and welcome to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat, urologic oncologist in Houston, Texas, and it's a pleasure to welcome to the forum once again, Dr. Sarah Psutka. Sarah, welcome.
Sarah Psutka: Thank you so much, Ashish.
Ashish Kamat: So, it seems like this year at any major gathering that involves patients, you are there, and you're leading the charge in different aspects of bladder cancer care. And you did this again at the BCAN breakout session, at the recent BCAN, which occurred in 2025 in August. So, it was an interesting topic. It was complementary medicine, how do we integrate that into our current tools, allopathic medicine, et cetera, coming together. So, I'm really excited to hear what you have to say about the summary because I unfortunately was at another session, so couldn't attend it. So, take it away, share it with me and the rest of our audience.
Sarah Psutka: Well, thanks so much for highlighting this. So, I think that's one of the big challenges of the BCAN think tank, is there's usually so many competing great breakout sessions, and I'm the same, I always wish I could be at all of them. This was a really fun one though. So, one of the charges that I've had over the last couple of years has been to start to develop conversations at the think tank around some of the supportive oncology work that I've been working on, in terms of facilitating preparation for surgery, some of the prehabilitation work that we've done, and a sidebar of all of that has been thinking a lot about toxicity management. And as I've been trying to learn more about how to do that better in my work at UW and the Hutch, I've gotten to know a lot of really amazing experts in the field.
And so, this was an opportunity to bring a couple of those experts to the think tank, to help educate us all on how we can integrate complementary medicine approaches to toxicity mitigation. So, the two folks who I got to work with who are just outstanding... And I've done some work with both Anna and Hannah before. So, Anna is an integrative oncology specialist from Winship Cancer Center at Emory. And Anna and I have actually run a course on this topic at the AUA, along with Viraj Master, and a number of other providers, and then have also done some thinking around this with the American College of Surgeons. And then, Hannah is one of my research collaborators here at the Hutch, she's also a partner in crime in terms of helping me give my patients opportunities to get fitter. She's an assistant professor of physical and rehab medicine, and our director of cancer rehab, and she's outstanding. And these two physicians brought some just really brilliant updates to our patients, and we had a really great conversation. So, the first thing we started with was really around definitions. And when people think about integrative oncology as a traditional allopathic provider, this is not something that I had any visibility on when I was really in training.
But it was interesting as I moved, as I've marched from East to West Coast, I've had to learn more. And in the Pacific Northwest, there's a real, I would say, openness to these integrative oncology approaches that I think is permeating care across the country, but it's especially something that I noticed when I moved out here. So, there's these traditional therapies that are more culturally based health practices, there's alternative therapies that are oftentimes used in place of conventional medicine. Complementary therapies, what we're talking about here are really meant to be used in tandem with conventional medicine, and the field of integrative medicine is evidence-based practices that integrate these complementary therapies into conventional practices with the goal of optimizing outcomes. And what we've noticed over the last several years is there's been significant increasing rates of the utilization and acceptance of complementary and alternative medicine across medicine. Interesting, surgeons are the least likely to integrate these, so we've actually been trying to... That's why the ACS actually had us give a course on this.
We've done a couple of courses with them on this topic. Because this is a huge industry, and people across the country in terms of healthcare expenditures, you can see that there are over $30 billion spent on these tools within one year, and a lot of that is out-of-pocket. And the interesting thing is, of course, there's varying degrees of evidence that are supporting the utilization of some of these tools, and so it's really important that we as providers have understanding of what works and what doesn't so that we can try to guide our patients towards evidence-based practices. And so, we focused on a number of... We hit the high notes in the two hours that we had. We looked at how we can use these tools for the management of perioperative nausea and vomiting and postoperative ileus, we talked about management of pain and anxiety, we talked about integration of physical activity and movement in cancer care, diet and nutrition supplements... Because that's a very common question that we get in clinical practice. And then I've actually run a trial that I'll share with you on how acupuncture can be beneficial in the setting of non-muscle-invasive bladder cancer, trying to understand that better.
And so, we highlighted that trial. We defined acupuncture and acupressure, because this is, I think, something that there's tremendous familiarity with in the lay literature, and acupuncture is a very commonly used complementary and alternative practice. The whole idea here is that there are specific pressure points where connective tissue kind of aligns, these practices deform the connective tissue in specific points that have been really defined by traditional Chinese medicine. And what's interesting though is that when we look at translational and animal models, we can see impact by that deformation of connective tissue on central opiate receptors. Interestingly, they can be even more powerful than that seen with analgesics, and you can actually block those interactions by giving Narcan, which sort of gets at some of the mechanism. And what's also interesting is that when we see that connective tissue deformation in translational studies, we see modulation of local inflammatory mediators, and some of that may get to some of the mechanisms of why these points are so potentially powerful.
We talked in terms of our overview of how these therapies can help. We went through the data for music therapy, for acupuncture in terms of the management of postoperative nausea and vomiting, and I'll tell you that there's, for example, in the current anesthesia guidelines, acupuncture is recommended as a... There's level 2B evidence to support its utilization to reduce postoperative nausea and vomiting, and so it's actually integrated in their guidelines for prevention of that. We talked about the role of all of these different therapies in postoperative ileus, and we shared with both our patients and our providers the way that they can actually integrate acupressure into their practices, which is something that I do at the bedside when I'm rounding on patients, if they are having specific issues. And then we talked about all of these different practices that can be beneficial for the management of stress, anxiety, and pain, which is incredibly important for our patients. We highlighted the Society of Integrative Oncology and ASCO combined guidelines, and showed the evidence for the integration of a number of these tools, which in the context of this talk, I won't have time to go through in detail. But it highlights the fact that there is an emerging and fairly robust evidence base for a lot of these practices.
And then, Hannah, Dr. Hunter, got into some of the work that we've been doing in terms of exercise. And I think we all know that exercise is recommended, we all know that it's important. All of my patients, I counsel them on exercise. But what Hannah's been helping me do is figure out how to operationalize that. And that's been the challenge. It's been really amazing to work closely with a rehabilitation medicine physician who has oncology specialization. And so, Hannah, Dr. Hunter, reviewed the evidence base to highlight how exercise may reduce cancer-specific mortality, cancer recurrence, et cetera. There's really robust data out there. And I don't know if we've been doing a tremendous job in oncology of actually integrating exercise in systematic ways into our care. We've been working on a number of different studies. And as we learn more about how to do that, we've tried to pull from various programs around the country. And I recently went to Houston, actually, at MD Anderson to learn from them about their exercise program, and just talk to them about how to operationalize some of this and make it practical so we can actually bring it to our patients. And we highlighted some of those programs, and also some of the evidence for specifically exercise in the setting of bladder cancer, which is emerging, but really encouraging, in terms of improvement of quality of life for patients with bladder cancer.
And then I ran a trial when I was at Vanderbilt, looking at acupuncture in the setting of BCG treatment for non-muscle-invasive bladder cancer, so we know how toxic BCG is for patients, we know that a lot of patients really struggle with the side effects of BCG. We ran a trial to see if acupuncture could mitigate some of those risks, it was a randomized controlled trial that's published, that was a phase 2, to see if we could, one, actually do acupuncture in a urology clinic, and two, we explored the effect of it. And the punchline from that trial was that we showed that you could do this in clinic, it was safe and efficacious. It didn't delay care, it didn't prevent patients from getting their BCG. Patients loved it, they absolutely loved it. And actually, the really interesting quality of life data showed that as patients got their six rounds of BCG, the patients who were randomized to the acupuncture arm, their urinary symptoms got better across the six weeks of BCG, which is obviously, Ashish, you know, that's not something we commonly see in practice. So, we had a lot of important takeaways that we reviewed, but basically these were some of the nuances of some of the nutritional recommendations that Anna talked about.
We talked about integrative considerations. A lot of this was really bringing an expert in, because as providers, we're not experts in any of this. But I started to work closely with my integrative oncology colleagues and have found it to be tremendously helpful for our patients. And then we just highlighted the fact that there's level 1 evidence for a lot of these practices. And I think that there's a lot of opportunities to leverage these complementary tools to our toxicity mitigation to help improve survivorship in the end, and treatment tolerability. And then also, I would say it's really actually an interesting area to be involved in as an investigator. I've very much enjoyed the work that I've done so far. We are hoping to run a phase 3 study that's going to look at this acupuncture protocol that we've developed, and patients are very enthusiastic about participating. So, I think it was a really great discussion, lots of enthusiasm from patients. And obviously it's a very interesting emerging field with a lot of, I think, potential to help us take better care of people.
Ashish Kamat: Absolutely, thanks so much. You mentioned a whole bunch of things, but I think it's really, really important about getting up and moving around, right? Because not only does it help everything that you mentioned, but I don't have a prospective study on this, but when it comes to BCG, I really will tell patients, for two reasons. Number one, you don't have to do the [inaudible 00:13:53], that makes no sense, but get up and move so the medication not only moves around, but then I noticed that the more active patients are, even with BCG in the bladder, the less symptoms they report.
I don't know if it gives them something to do, releases certain cytokines or whatever it is. But activity across the board is something that we as a human culture have gone away from, right? So, it's something clearly to bring back. I think the other thing that you mentioned, and I saw that in some of the small print here and there, you didn't call out specifically, but I think it's really important, one of the things that your group highlighted, at least I saw from the slides, is the sourcing of these supplements is critical. Could you share with us a little bit as to what specifically you discussed on the panel there?
Sarah Psutka: Yeah. So, Anna actually got into this in detail, and I learned a tremendous amount from her. I think a lot of the supplements... One of the challenges with supplements is that many of them are... Well, the vast majority of them are not regulated by the FDA. And so, when we purchase supplements, depending on where we purchase them from, we may or may not be getting what we think we're getting. So, Anna actually highlighted, and I'm happy to share it, we can maybe tag it with the podcast so that people can actually use the websites.
There are a couple of sourcing locations that are fairly reputable, but for example, if you're just buying something on Amazon, you don't necessarily know what you're getting. And it's important because different supplements... So, let's just take magnesium, for example. Magnesium has a number of different benefits, it can be helpful for sleep, it can be helpful for constipation, it can be helpful for muscle spasms, it can be helpful for pain, but there are actually different compounds that are used for each of those indications. So, that's where working with a naturopath or an integrative medical physician specialist can be very beneficial to make sure you're getting the correct supplement and also then sourcing it from a reputable place.
Ashish Kamat: And-
Sarah Psutka: And from a cost perspective, that's important as well, because obviously, like we said, this is a many, many, many tens-of-billion-dollar industry.
Ashish Kamat: Yeah, no, the amount of money that pours in there is humongous, but it reminds me of the time when, for prostate cancer, there was PC-SPES, and it had warfarin as a contaminant, and patients were feeling better because obviously they had improved blood flow, but then they were dying of anticoagulation-related toxicity. So, it's really, really important to make sure that there's no contaminant, let alone warfarin, right?
Sarah Psutka: Well, that's an extreme and very important example. But I would say even... So, just going to supplements, I think there's a lot of information, there's a lot of misinformation out there. And especially as you start to see with social media, we have influencers who are recommending specific... Posed as complementary or alternative benefits that may or may not have the evidence-based behind them that, for example, are the things that are included in the ASCO and SIO guidelines. I think as providers, it's really important that we actually ask patients, so what exactly are you taking? What supplements do you have? High-dose garlic, for example, is an anticoagulant, so you need to make sure your patients stop taking that before procedures, things like that.
So, it's just relevant to say... When I talk to patients, I say, look, I fully am supportive of all of these complementary therapies, but I do need to know what you're on so I make sure that that's not going to interact with any of the other things that we're doing. And also, maybe sometimes it can be helpful to bring an expert into the mix to actually go through those lists and make sure that we're taking the right things. So, I really appreciate it. Anna is a very thoughtful... She has a very thoughtful counseling style around how to make sure that people are getting what they think they're getting, and also making sure that it's maximally efficacious and not just dollars down the drain.
Ashish Kamat: Right. And just as your center, most of our centers have integrative medicine groups and experts, but I think it's really important for everybody taking care of patients, not just cancer, but across the board, to actually be interested in this, right? Because just because it's not taught in our medical schools doesn't mean, A, that it might not work, but more importantly, it doesn't mean that your patient's not taking that. And there are numerous times patients, when I ask them, hey, what else are you on? They'll sheepishly admit to me, but then also admit to me, nobody ever asked us about this before, I've been taking this for three years and nobody ever asked me this before. So, work like what you've done at the think tank, and just raising awareness of this is really, really, I think, a crucial first step. And I'm glad people will be able to listen to this on UroToday and actually gain some insight. And yes, if you could send some of the links, we'll put it down here, and I'm sure it'll be heavily used resource. So, Sarah, once again, thank you for taking the time.
Sarah Psutka: Thank you so much, Ashish.