Sarah Psutka: Thanks for having me too.
Tian Zhang: Tell us a little bit about your practice at Fred Hutch. We're really interested in women surgeons taking care of women with bladder cancer. So tell us a little bit, give us a flavor for what you do.
Sarah Psutka: Well, I think my practice from a clinical standpoint is pretty divided between kidney, bladder, and testes cancer. The testes cancer obviously doesn't apply to taking care of women. But I would say I see a fairly robust mix. Obviously, kidney and bladder cancers are more prevalent in men, but we do see a lot of referrals for women coming to the Hutch. I think one of the themes and one of the challenges in taking care of bladder cancer in women is that it's often diagnosed at a later stage. That's something that, if we make any public service announcements, this is something I talk about wherever I go. It's often underdiagnosed because of the assertion that hematuria in women is infection first, and then a lot of times it's not further followed up. So we get a lot of referrals, unfortunately, for women who have been dealing with hematuria for some time and then have a late stage presentation. And I see a lot of upper tract urothelial carcinoma in women as well. And also, we have a big Lynch practice. So a number of patients with Lynch syndrome who have tract urothelial carcinoma. So I would say I actually have a fairly, from a gender perspective, for most urologists, I have a fairly well split practice. And part of it may be referral patterns, but also just based on the disease that we're seeing.
Tian Zhang: Yeah. And certainly the trend across the country for women is that they get diagnosed, unfortunately later stages and more advanced disease. How are you counseling women as they're coming in with newly diagnosed disease or you're making the diagnosis yourself doing their cystoscopies?
Sarah Psutka: The counseling always comes back to basic principles. Regardless of who you're talking to, it's a risk-stratified guideline-based approach. I think the things that really come out in these conversations whenever I meet any patient the first time, it's really about educating them about their disease process. Because I think that bladder cancer, despite the fact that it is an incredibly prevalent cancer, is so not well represented in kind of our public conscious public media. It's not something that there isn't a huge lobbying body behind it. Although organizations like BCAN, IBCG, have really done a great job, I would say, of increasing awareness of the disease period. And also again, making it kind of okay to talk about. We think about bladder cancer as... It sort of gets lumped into the bucket of cancers that are uncomfortable to talk about openly. But I really try to give people space to ask, what is this? Where did it come from? We go through a very detailed assessment of exposures because we know that it is one of the cancers where there's pretty clear epidemiologic risk factors.
And then of course, family history is a big part of it too. And that often gets us into now our ever increasing utilization of genetic counseling in these patients. Spend a lot of time talking about that. And then, after the education piece, when I'm presenting treatment plans, a big part of it is actually pulling out from patients, what are their priorities? Because all of the treatments we have fairly substantial implications for physical function, sexual function, and sort of how life gets lived. And especially, of course, if we're talking about patients who are looking at a radical cystectomy, it's really important to understand what does a successful outcome look like for those patients and giving patients not only the space to talk about it, but actually the space to think about it and come back with really well considered conceptions of what that is. Because I think a lot of us wouldn't actually have that answer at the tip of our tongue without sort of the opportunity to talk to friends and family and loved ones to actually explore what that looks like.
Tian Zhang: That's really life altering, right?
Sarah Psutka: Right.
Tian Zhang: When you have your bladder removed and have to live with an ostomy or neobladder.
Sarah Psutka: Yeah. And the implications for sexual function, for cosmesis, for how clothing is going to fit going forward. People have a lot of questions about how that all sort of comes together. But even if we take a bladder-sparing approach, what urinary symptoms are going to look like, really understanding the degree of bother that a patient's urinary symptoms are causing for them. I would say that a lot of my first consultation with somebody is really exploring what's the impact of the cancer on their life already. And then again, what's their wishlist? And then it's all about tailoring a program that's going to optimize our ability to deliver on that.
Tian Zhang: Great. Yeah. No, thanks. That's really perfect. Talk a little bit about those treatments, especially for non-muscle-invasive bladder cancer. We've seen a number of new intravesical therapies coming through. Any effect, more on women, or differences that you'll approach those intravesical therapies with women more than men, or vice versa?
Sarah Psutka: That's a really good question. I would say there's not a lot of robust data that I think would support differential side-effect profiles in men versus women across, especially the novel agents. I think that that's actually probably something we need to look at because it's women, because of the lower prevalence, it's sort of a three-to-one ratio men to women. In bladder cancer, we don't get as much data about women and women tend to be underrepresented on those trials. It's nice if you can sort of oversample in some situations to get a bit of a more generalizable sample. But I would say, depending on a priority, like stress incontinence, that can have implications for the ability to just hold an agent, urgency and overactive bladder, which can be more prevalent in women certainly can sort of inform the conversation around what, especially for most of these newer intravesical agents do cause they're thankfully very safe, but the side-effect profile is predominantly urinary urgency frequency, irritation, sometimes bladder pain, and then as sort of the primary toxicities we see. So if somebody already has an overactive bladder that is really affecting their quality of life-
Tian Zhang: And make it worse before that.
Sarah Psutka: ... my suggestion, that I'm going to be putting all of these agents into their bladder, unfortunately, is going to pretty substantially impact their quality of life and can affect how they live their lives. We actually see there's some really nice data that's been put out by, that sort of has... It will be published soon, but it's patient survey data about how bladder cancer impacts one's ability to live one's life. There'll be some workshops around this at the AUA. One of the most striking statistics is 95% of patients with bladder cancer that their cancer has impacted their ability to participate in sort of an event or a family event, a social event, an activity that they love. It's prevented them from doing the things they care about, kind of across the board. That means that essentially, universally, this cancer substantially prevents people from being able to engage in life as they would like to.
Tian Zhang: Yeah.
Sarah Psutka: That sample was largely weighted towards folks with non-muscle-invasive disease. So I think that it's really important to prepare patients as they're thinking about what treatment options they're going to go for, to understand what that's going to look like in real time. So, spend a lot of time thinking about that. Patients who have a history, for example, of that bladder pain syndrome interstitial cystitis, you know that they're going to really potentially struggle with any of these therapies. And bladder cancer can just be innately irritative as well. So that's important. And then getting into the muscle-invasive conversation, of course, there's all kinds of implications for whether we're thinking about pelvic organ-preserving surgeries or not, certainly hormonal preserving. So an ovary-sparing cystectomy, which is now what we preferentially try to do for, essentially everyone under the age of 75 based on ACOG guidelines, but historically that was not the case. Preserving even postmenopausal ovarian function with respect to especially testosterone production is really important for all kinds of organ function. So there's a lot to get anatomical-
Tian Zhang: Consideration...
Sarah Psutka: ... We don't necessarily think about, and thankfully it's something that we, with thought leaders who are really working on improving our understanding of how to better care for women with urothelial carcinoma, we're getting more data around the impacts of the treatments in women. Actually, there's a bit of a dearth there.
Tian Zhang: Any advice for urologists in the community, academic centers, and their approach to women with cancer?
Sarah Psutka: It's probably, it's not special for women. It's something that we probably just need to do a better job of for everyone we take care of. I think it's really important to totally understand when someone walks in, what their symptom burden at baseline looks like. I think a lot of patients are, oftentimes will minimize their symptoms. And I do try to create an environment in our office where people feel really confident saying like, "This is how this is impacting me on a day-to-day basis." And sometimes you have to ask the question a couple different times because patients may not necessarily know what you're getting at. But getting at urinary symptoms, getting at pain, getting at also their comfort and talking about it, getting at social support around this diagnosis is critical. A lot of patients feel very isolated by the diagnosis. And then getting to that question around treatment priorities. At the end of the day, we've got to elicit priorities so we can match treatment to patients' goals. So those things are important.
And then education, I mean, whenever I talk to a woman about... If I'm seeing a woman, for example, who has a low-risk or an intermediate-risk bladder cancer where we're going to be establishing, or any of the non-muscle-invasive diseases, I guess it applies to everyone, where we're going to have kind of a lifelong partnership, patient and provider, right? I want them to feel confident and comfortable calling me if they see blood in their urine again, because sometimes that is often a signal of a recurrence, and I don't want it to be written off as just another UTI, things like that. So you really want to establish a great relationship where patients feel like they can talk to you about some pretty personal things and make their needs known.
Tian Zhang: The partnership is so important.
Sarah Psutka: Yeah.
Tian Zhang: Great. Any takeaways, final thoughts?
Sarah Psutka: I really do, when I'm working with residents and fellows, I like to talk to people about how to ask the question of what matters to patients. And I think that we don't have a lot of time in our conversations with these patients. We don't have a lot of time to educate, elicit preferences, build a rapport where you're basically setting up... Again, I say to all my bladder cancer patients, we're going to be friends for a really long time, especially if we do it right.
Tian Zhang: Which is good.
Sarah Psutka: Because if we do a good job and we just turn it into a, "We're seeing you every couple of months, then every year for surveillance and the cancer's not coming back," that's the best case scenario, but it's still a chronic illness. I just want patients to feel confident saying, at some point, if something's really bothering them to bring it up. So creating that environment where they can do that, I think is really critical. And then again, asking what's important, and making sure you ask the hard questions that patients may not feel confident just volunteering about things like sexual function or even talking about cosmesis. Some patients may feel that they shouldn't be bringing that up, but how they feel about their body impacts their quality of life. We know that. So I think that, make space, make space to talk, even when it's hard. I think it really helps.
Tian Zhang: Thank you for all you're doing, caring for all the women in your clinics, teaching all your fellows, and making that space and making them comfortable.
Sarah Psutka: It's a real privilege, what we do, and it's also the best part of the job, right? It's one of the things that we're lucky in oncology, we are lucky because we do have these very long relationships with our patients if things go well, and that is one of the perks.
Tian Zhang: Absolutely. Thanks for joining me.
Sarah Psutka: Thank you.