Katie Murray: Yeah, of course. Thanks for having me.
Zachary Klaassen: So let's reverse the question. Let's start about who we should still be doing repeat TURs on. Who are these patients that there's no option for non-surgical management?
Katie Murray: Yeah. So initial diagnosis, right?
Zachary Klaassen: Sure.
Katie Murray: You come in, somebody with hematuria, that pathology is so important. So there's two pieces to that pathology being so important. Getting the tumor out completely. Therapeutic and then diagnostic. You get that pathology so you know exactly what you're dealing with. So I then have to say the completion of the TUR is so important, bread and butter urology, but the mainstay of bladder cancer. We have to do good TURBTs. And so that means if a patient needs to go back for a completion TURBT irrelevant of what that pathology is, it's something that I always remind my residents. It's okay...
Zachary Klaassen: Great point.
Katie Murray: To do that. Of course we have the indications when you have high-grade disease that patient needs a resection, a re-staging TURBT or a large volume high-grade TA disease or one that I didn't resect myself and you don't know what it looks like, I think is an important re-resection. So I think that's probably of utmost importance. And anytime that you feel like that's what needs to do, that gross appearance on your cysto, if it looks different, if it looks concerning, if you want to put some blue light on it to see if you have concomitant CIS, never wrong to go back to the operating room to do a TURBT.
Zachary Klaassen: It's always our fallback no matter what, right?
Katie Murray: Yeah, absolutely.
Zachary Klaassen: So let's pivot now. So are there patients out there where you may consider, okay, we see a pattern of disease, maybe it's low-grade, maybe other options, but where we may be able to either watch it or do non-surgical management.
Katie Murray: Yeah. I think this is a growing world that we have in urologic oncology and in urology overall and it's unnecessary. I think we're there. We don't need to be doing an operation on all of these individuals, but the challenge we have today is figuring that out. I think we're in that early, early phase of doing that. So the ones I think that are safe when the natural history has told you this is recurrent low-grade disease, right? You know what it looks like, you've taken a picture, it's in their chart four different times of what that is. I think that's a great patient for non-surgical management and especially that kind of story in a patient who's elderly, taking them to the operating room is impactful to them, to their families, to their lives and it's risky. It's the one that I show up and the anesthesiologist says, "Katie, what are you doing?" Like this joke that we have going on. And so it's nice to have that non-surgical management. So when I think about non-surgical management, what does that mean?
Zachary Klaassen: Sure.
Katie Murray: It can mean you see a small tumor when a recurrent low-grade patient and maybe it's in a tough spot to fulgrade or do something and you say, "Well, you hadn't had a recurrence in a while. Let's keep our eye on this. Come back and see me in three or four months after your vacation, et cetera, and we'll look at it again." Surveillance is not a terrible idea. Chemoablation can be an idea, right? The new reverse thermal hydrogel mitomycin, Zusduri, induction course only with high dose chemotherapy. Now that's a little odd for us to think about, but chemoablation's real. It works.
Zachary Klaassen: It works.
Katie Murray: On these papillary tumors. And so that's a non-surgical management. I also will throw in as a non-surgical management if you have the capabilities to do in-office fulgurations.
Zachary Klaassen: Totally. Yep.
Katie Murray: I consider that essentially non-surgical. It's procedural, yes.
Zachary Klaassen: But it's some anesthesia, which is nice for these patients.
Katie Murray: Yeah, exactly. So anyway.
Zachary Klaassen: No, that's great. And I think when we think about these patients, whether it's surveillance, whether it's Zusduri, whether it's in-office fulguration, is there either clinical or disease factors such as age, comorbidities, number of recurrences, time between recurrences where you think, maybe we should be doing a TUR on this patient?
Katie Murray: Yeah. So I think timing is a big deal of recurrences and it might be a little bit opposite of what you think, right? If it's been a while between recurrences, that might be a person that the disease is reset and I might want to do a TURBT on and make sure that I'm still dealing with the same disease as I thought I was.
Zachary Klaassen: Yeah, good point.
Katie Murray: Multifocality can be nice to do a TURBT. On the flip side, I also remind my trainees that multifocality increases your risk of missing a tumor.
Zachary Klaassen: Sure.
Katie Murray: And so I like the idea of a chemoablation in that actual patient population age, comorbidities. Of course we don't love taking the older patients to the operating room. On the flip side, you don't really want to be taking these younger patients to the operating room and scarring up their bladders when they're... We all have the 40, 50 year olds who unfortunately end up with this recurrent disease.
Zachary Klaassen: When you're thinking about surveillance or chemoablation, I typically will do cysto. I know their disease history, cytology. Are you doing anything else to say, "Hey, I think you're going to be safe to either do surveillance or do chemoablation."
Katie Murray: I'm not. I've explored into many biomarkers and things that I would love to augment. I don't trust anything yet. I don't think anything's truly quite ready for prime time for that kind of surveillance.
Zachary Klaassen: Yeah. And I think too, our eyeballs tell us we see it and we know the history that they've had going into that system.
Katie Murray: Correct.
Zachary Klaassen: Last question, around shared decision-making. It used to be like, you have a tumor, we're doing a TURBT. It's pretty black and white. But now it's coming into a new realm of shared decision-making for these patients. Should we chemoblade, surveil, do a TURBT? How do you handle that with your patients?
Katie Murray: Yeah, it's a little bit tougher because it adds complexity into a very large group of patients and shared decision-making takes time.
Zachary Klaassen: Yes, which we don't have.
Katie Murray: And it's a lot, it's a lot for us. But it's also a lot for the patient and for the family. And oftentimes shared decision-making can end up into, "Well, we're going to go home, we're going to read about this, we're going to think about it, and then we'll let you know." Well, that's an extra Epic message and phone call and some of the other things that come along with that.
Zachary Klaassen: Good points.
Katie Murray: That being said, setting the stage early when you have the time, I set it now at the time of initial diagnosis and say, "This is kind of the information if and when you have the recurrence because these are my percentages of the likelihood of that recurrence in happening, we're probably going to be at a decision pathway. Are we going to go down this route or are we going to go down this route?" And I think that's helped a lot from that period of time. But I think when I think of a low-grade patient, for example, and I TUR them and they're coming back and we're talking about that pathology and I say, "Okay, you get one free tumor, your first one's free." And then that first cystoscopy after that is so telling as to what that natural history is going to be.
Zachary Klaassen: You can see where it's going. Yeah.
Katie Murray: And that can be that point of decision to say, "Okay, now which path are we going to go down?" It can save you a little bit of time from going through that conversation with everybody because there are people that won't recur.
Zachary Klaassen: Yeah, absolutely. Great points. Anything we haven't hit on? Any take home messages before we wrap up?
Katie Murray: No. Let's see, wrap it up. You have to do a good TURBT. It's the mainstay of bladder cancer, at least at some point in initial diagnosis before you move on to these non-surgical managements. But we're growing, we're getting out there, we're doing some cool things for our patients.
Zachary Klaassen: The space is growing and it's good for our patients. It's good for us to have options. Katie, always good chatting with you. Thanks for joining us.
Katie Murray: Yeah. Thanks so much.