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Sam Chang: Hi, my name is Sam Chang. I'm a Urologic Surgeon at Vanderbilt, and we are quite fortunate to have Dr. Suzanne Lange here with us today, who's going to highlight as she led work based at MD Anderson looking at actually a scoring system to help determine what we do for Upper Tract Urothelial Carcinoma.

Currently, Dr. Lange is a Urologic Oncologist and practices in Colorado Springs. She works for UC Health, and we are quite fortunate to have her today go over some of the highlights from this manuscript. This article on manuscript came out, actually, in April of 2025 in the Journal of Urology, and we've asked her to give some highlights. So, Dr. Lange, thank you for spending some time with us.

Suzanne Lange: First of all, I would like to thank you guys for having me here today and being able to share this work. And I would also like to thank my co-authors who helped me with this paper. This project was the development of a scoring system to help us communicate and understand patient anatomy and phenotypic tumor factors that could affect decision-making and outcomes for patients with upper tract urothelial carcinoma.

We all know that endoscopic management is becoming an increasingly acceptable option for select patients and is becoming incorporated into guidelines more often. As we increase our treatment options, this can make decision-making more complex and harder for patients and providers. And most of the predictive tools in this space focus on predicting high risk features at time or on final pathology with radical surgery or recurrence and are heavily affected by pathologic factors.

Pathology rightfully drives a lot of decision-making in this field and for these patients. But we thought that there is a variety of anatomic and tumor characteristics that drive success as well. So our goal was to consider what factors a surgeon assesses at time of endoscopic evaluation. And how can those be communicated and potentially affect outcomes, especially taking into consideration endoscopic management?

And so the objectives of this study were to identify these anatomic and tumor phenotypic characteristics, gain consensus on what are the most impactful, and then develop an assessment score. And then we wanted to perform an initial validation. So as a rare cancer, trying to find all the possible variables in retrospective review or doing a prospective study would take a significant amount of time.

And so we decided that a good place to start would be gathering expert opinion. So the initial portion of this study was a modified Delphi study. A Delphi study uses multiple rounds of surveys related to an intended subject to gather consensus. And the goal is to systematically collect data of expert opinions to turn that into actionable information.

We sent this to expert urologists, including those with endoscopic and oncologic-specific fellowship training. We were fortunate that 30 participated, and we performed two surveys. The first confirmed that there is a need for this assessment score, who it may apply to and evaluated variables that could be impactful. And then we took those variables and put them into a scoring system with five categories of related variables and assigned weighted anchors to represent the degree of negative impact of each variable.

And then we showed the previous round data in the scoring system to experts, and asked if they agreed on those categories and the anchors. Once we developed our final score, we did an internal validation with a retrospective chart review looking at how patients were managed. The focus was primarily on the surgeries that they received.

So this is a visual representation of the data from the first round of surveys. It shows the expert opinions of the extent of positive or negative impact of these variables on outcomes. And then the degree of agreement between the experts in the surveys is represented on the vertical axis. So the more they agreed, the higher it was in agreement and how much we weighed that variable in consideration for the score.

So then, we created this scoring system. The five different categories are we felt were related variables. And they're represented by the horizontal bars. And we assigned the numerical anchors related to degree of negative impact. So 0 really mean it's not going to impact. They don't think it's going to impact the case. A 1 or 2 is an increasing negative impact on the success.

And so you add the number from each category to make a composite score between 0 and 9, 0 represents a very straightforward or simple case, and 9 would represent a very complex case. And so here we have the final scoring system. We then run our retrospective review. We looked at a total of 110 renal units. The median follow up was 3.5 years. And the analysis found that as the endometry score increases, the likelihood of more intensive intervention increases.

We wanted to look at how this could be applied moving forward. And so we categorize the score ranges into low, intermediate, and high risk groups. In this table, we are looking at how many patients in each of these risk groups required either one endoscopic procedure, which are the green bars, multiple endoscopic procedures without radical surgery, which is the yellow, and then those who ultimately required radical surgery, which is the red. And so from this information, we could roughly estimate the likelihood of someone with a specific score requiring radical surgery.

So in this study, we developed an easy-to-use tool that could be used to help counsel patients, standardize reporting variables, and further evaluate the relationship of these variables to outcomes. There's a lot of future work that should and could be done in this space. We think it's a good framework to start with. But understand that the predictive capacity is limited at this time with a small cohort. But we do think that the expert opinions are very valuable.

And so we understand that there could be adjustment of the variables or of the anchors in the future, and that there's a lot of different outcomes that we could consider here. So again, I would love to thank my co-authors for all their work for this project, and then all the experts who provided input for this project as well, because we obviously could not have done it without them. Thank you,

Sam Chang: Dr. Lange, that was great. As you go through the different variables, you saw how they agreed that upward arrow box and then positively versus negatively. As you guys gathered these variables, were there any that surprised you or the individuals at MD Anderson that ended up weighing more than you normally would think?

Suzanne Lange: That's a really good question. I don't think there was anything that specifically was more or less than we think. I mean, a lot of it aligned with what you would expect. But I mean, you have to study that moving forward. And some of it, there is data out there that correlates with some of this. And I think that's why you get their expert opinions.

Sam Chang: Right.

Suzanne Lange: The biggest thing that--

Sam Chang: I was wondering how they aligned with the guidelines regarding risk of tumors as opposed to-- it's a different way to look at things. It's the impact on endoscopic management versus risk of tumor. And you would think that they would align that the lower the risk, the better in terms of endoscopic management, et cetera.

But that's why I think it's really interesting to see the impact of architecture or other things that you all mentioned. So you were talking about how this is really a start, that we can now move forward. What are your plans or what are the plans at MD Anderson in terms of the next steps with this project?

Suzanne Lange: Next steps that we've discussed is doing an assessment of complications in these patients. We did look at the numbers here on who required procedures more for strictures. Or was it because of strictures? Or was it because of advancement of disease? Those are different things you can look at? I know there's multi-institutional endoscopic management databases. And I think that would be an excellent place to start moving forward and a great project.

Sam Chang: You could use the score, and then you know the management of the outcomes and just to see how well it matches, I think that's fantastic.

Suzanne Lange: Exactly.

Sam Chang: So Dr. Lange, in today's practice, I've got my Journal of Urology, I've got different ways to assess this. Tell me how I can-- you mentioned it in your conclusion slide. How can I use this now perhaps with the next patient I have coming in with an upper tract tumor?

Suzanne Lange: I think you could take a look at this. Look at-- I mean, you can calculate the score. That would be amazing if people were using it and then start using it in your practice and seeing what those outcomes look like yourself. Like I said, it's not-- we validated in our internal cohort. It's got more work to do.

But I do think that it's very meaningful data and that there may be some variables that people thought, oh, well, when I see this right now, this is how I'm managing it. But the experts are managing it this way. And that's like, how long does it take for things to actually go into practice based on data? It takes a while. But if people start looking at this more actively, they may make changes sooner.

Sam Chang: Absolutely. I think by looking at the variables and the scoring system that you all have set up, we can use that as we tell our patients, there's a real chance that we'll have to do x and x because of these variables. We can-- so I think it gives us a more cogent way of helping in our counseling.

You're right. It doesn't match exactly with all of our individual different practices, not yet, but it definitely serves as a framework of discussion and jumping off from there. So Dr. Lange, thank you so much for sharing your manuscript that was in the April Journal of Urology. And I think we really look forward to just as you say, further research showing how we will integrate this further in our practice. So thanks again.

Suzanne Lange: Thanks for having me.