Armine Smith: Thank you. Thanks for having me.
Tian Zhang: Tell us a bit about your clinical practice at Hopkins and in particular, your attention to treating women with bladder cancer.
Armine Smith: So at Johns Hopkins, particularly at Sibley Memorial Hospital where I primarily practice, we have this wonderful initiative, the Women's Bladder Cancer Program. We're very fortunate. Jeanie Hoffman-Censits and I kind of had common interest. We had a strong support from our leadership, particularly Stephanie Greenberg, who co-founded the Greenberg Bladder Cancer Institute. What this program grew from is the realization that women have very distinct problems in the bladder cancer treatment area, and they're not being addressed in these programs that kind of look at all the patient population being treated in urological and medical oncology clinics. Instead of just having a standalone clinic, this was more of a multidisciplinary collaboration between medical oncology, urology, social work, physical therapy, gynecology, and all of these kind of programs came together instead of just being on the ad hoc referral basis.
What we've done is we've incorporated female-specific questionnaires, normalized organ-sparing conversations about women, incorporated female-specific anatomy kind of training in our fellowship and residency programs. And our research agenda also now involves female-specific questions in bladder cancer. I think one of the things is importantly, the representation matters. A lot of women feel heard and seen better when they come to our program because they have some female providers. Bladder cancer is sometimes difficult conversation because it involves topics like sexual intimacy, urinary control, pelvic pain. So when they have more women in the program, in a variety of kind of roles, they feel like they can be understood better. So a lot of women travel significant distances to come to our program.
Tian Zhang: Yeah. Sounds like quite a referral and catchment to bring in all the women. And I was thinking, gosh, not many centers around the country have a program dedicated to women's bladder cancer treatment, so kudos to you all. What are some of the challenges that you've seen and some of the initiatives you've taken to counter those challenges when treating women with bladder cancer who may be presenting with later stage disease, for example?
Armine Smith: Yeah. I mean, just yesterday we had this panel at the GU ASCO that was composed of multiple kind of specialties. And the message was this, there are disparities when we treat women with bladder cancer. And some of the issues that we're encountering are delay in diagnosis. So hematuria, a lot of the times, is treated as maybe menses or recurrent infections before they get referred to urologists. So that causes a delay and potentially upstaging. Women are underrepresented in clinical trials. So I think we have a lot of times, hard time extrapolating this data to include women or focus more on women when we try to answer these clinical questions. There are biological differences contributing to all of this. Hormonal influences, immune responses, differences in the tumor microenvironment, microbiome, all these things that we haven't accounted for in the past. Finally, psychosocial functional consequences of treatment are often not addressed in women specifically.
Tian Zhang: Yeah. And so do all of that well, you're seeing your whole practice and really focusing on women, which is really great. So how do you try to counter those challenges when you're in your daily practice and seeing your patients?
Armine Smith: Well, I think, like I said, representation is really comforting for women and normalizing these conversations about intimacy, sexual side effects of the treatments. Having more female-specific, like I said, quality of life measurements, sexual questionnaires, these are all the things that we can start advancing the field in this direction.
Tian Zhang: Are some of your questionnaires adaptable for other clinics around the country? How you've been spreading the word for women with bladder cancer?
Armine Smith: At the meetings like this. I think in the media, more advocacy that we can have. Bladder Cancer Advocacy Network is a great opportunity for patients and providers to learn about this and hopefully implement some of the things. The questionnaires do not have to be bladder cancer-specific. So the sexual questionnaires are applicable across variety of different specialties, but also we have these bladder cancer-specific questionnaires.
Tian Zhang: So much that really impacts women who are dealing with new diagnoses and their treatments. So there's a whole wave of new treatments for non-muscle-invasive bladder cancer. You, as a surgeon, are using a lot of them. Do you see any difficulties or differences in how you would approach intravesical therapies for women versus men?
Armine Smith: Well, this is where we need more data. As I said before, women are underrepresented in clinical trials, so sometimes it's hard to extrapolate. Molly Ingersoll yesterday presented some compelling data showing hormonal influences and immunological differences in women's bladder cancer. These will likely affect the prognosis and treatment, but we just don't know yet. In addition, the urinary microbiome is probably going to be different. We're looking at it very seriously in our patients. Over time, we'll get some more information, but for now, we're still trying to figure it out.
Tian Zhang: Yeah, that's great. And from a surgeon, you're a woman urologic oncologist taking care of women with bladder cancer, do you see that being a benefit? I imagine it would. And how does it play out in your practice?
Armine Smith: Yeah, it definitely does. It offers a benefit for patients who want to be heard, their comfort in bringing up such issues with me as body image, sexual issues, hormonal challenges with the treatments. I think it also affects my kind of personal interest in the surgical anatomy and organ preservation, nerve preservation, and accounting for all these survivorship issues that women encounter after these treatments.
Tian Zhang: Sure. I imagine the reconstruction and ostomy function and placement, all of those have impact when you're talking with women and how they're going to deal post-op after their surgeries. What do you think urologic oncologists everywhere in the community oncology practices, in the academic centers, how do you think we can all approach our patients better with women with bladder cancer?
Armine Smith: Well, number one, measure functional outcomes, implement these questionnaires, or at least show interest in these kinds of questions that we're asking now. I feel like the functional outcomes belong near the survivorship curves. Maybe this is going to be more routine over time. As urologists, we need to be... and I had my talk yesterday also focused on that. Bladder tumor resection is often the first step in the treatment of bladder cancer. And because women have thinner bladders, a lot of times they are understaged, so they don't have as deep of a resection. So be more deliberate about these resections. Avoid reflexive extirpation, very radical surgery, normalize conversation about intimacy, advocate for better representation in clinical trials for women, and support research to better understand these differences.
Tian Zhang: Yeah. Fantastic. They're so practical, all of these points. And importantly, we need to enroll those trials and think about representation for our women in newer therapies. Great. Any takeaways for our UroToday audience?
Armine Smith: Yes, absolutely. So women with bladder cancer require a sex-specific consideration, as I kind of alluded to before, not extrapolation from male-dominant data. Disparity is most likely a combination of biological, anatomical data, some sociological kind of issues that are causing delay in diagnosis, under-representation in trials. A cystectomy is a big surgery, and we used to think about it as a very radical surgery, but I feel like we're at the stage where we need to look more into the precision and not the radicality of that surgery. Big proponent of organ-sparing, but organ-sparing surgery alone is not the same as functional sparing. We have to build in more education and our interactions with the patients and the cancer survivors. I think those are the things that change the outcomes. And then if we want to close the gap for women with this disease, we need to integrate surgical quality, more research, structured survivorship in our clinics.
Tian Zhang: Yeah. Fabulous. So great take-home points, and I hope we can implement all of them to be more mindful and bring in all of that to our practices when we're seeing women with bladder cancer. Thank you so much, Armine.
Armine Smith: Thank you.