Gender Disparities in Bladder Cancer Care and Treatment Considerations for Women - Jeannie Hoffman-Censits & Armine Smith
April 7, 2025
Leslie Ballas speaks with Jeannie Hoffman-Censits and Armine Smith about gender disparities in bladder cancer care. Drs. Smith and Hoffman-Censits highlight how women often face delayed diagnoses because their hematuria symptoms are frequently dismissed as UTIs, requiring multiple provider visits before reaching a urologist. They note that women are commonly diagnosed at later stages, limiting treatment options and affecting survival outcomes. The physicians discuss how female patients have different anatomical considerations, treatment decision factors, and quality of life concerns that have been historically underrepresented in bladder cancer research and clinical trials. Both doctors emphasize the importance of addressing female sexual health and fertility preservation, areas traditionally overlooked in urologic oncology, and share how their specialized program creates a medical home for women with bladder cancer, validating their unique experiences and needs.
Biographies:
Jean Heather Hoffman-Censits, MD, Assistant Professor of Oncology, Co-Director, Women’s Bladder Cancer Program, Greenberg Bladder Cancer Institute, Co-Director, Upper Tract Urothelial Cancer Multidisciplinary Clinic, Johns Hopkins University, Baltimore, MD
Armine Smith, MD, Urologist, Director of the Johns Hopkins Urologic Oncology Institute at Sibley Memorial Hospital, Johns Hopkins University, Co-Leader of the Women's Bladder Cancer Program, Greenberg Bladder Cancer Institute, Brady Urological Institute, Baltimore, MD
Leslie Ballas, MD, Director, Hematologic/Bone Marrow Transplant/Cellular Therapies Disease Research Group, Cedars-Sinai Medical Center, Los Angeles, CA
Biographies:
Jean Heather Hoffman-Censits, MD, Assistant Professor of Oncology, Co-Director, Women’s Bladder Cancer Program, Greenberg Bladder Cancer Institute, Co-Director, Upper Tract Urothelial Cancer Multidisciplinary Clinic, Johns Hopkins University, Baltimore, MD
Armine Smith, MD, Urologist, Director of the Johns Hopkins Urologic Oncology Institute at Sibley Memorial Hospital, Johns Hopkins University, Co-Leader of the Women's Bladder Cancer Program, Greenberg Bladder Cancer Institute, Brady Urological Institute, Baltimore, MD
Leslie Ballas, MD, Director, Hematologic/Bone Marrow Transplant/Cellular Therapies Disease Research Group, Cedars-Sinai Medical Center, Los Angeles, CA
Read the Full Video Transcript
Leslie Ballas: Hi, my name is Leslie Ballas. And I am a radiation oncologist at Cedars-Sinai in Los Angeles who specializes in GU radiation oncology. I am honored to be joined today by Dr. Jeannie Hoffman-Censits, who is an associate professor of oncology and urology at Johns Hopkins University and the co-leader of the Women's Bladder Cancer Program as part of the Greenberg Bladder Cancer Institute.
I'm also honored to be joined by Dr. Armine Smith. She is an assistant professor of urology, Director of the Johns Hopkins Urologic Oncology Institute at Sibley Memorial Hospital, and also co-leader of the Women's Bladder Cancer Program as part of the Greenberg Bladder Cancer Institute. Thank you so much, both of you, for joining me today.
Jean Heather Hoffman-Censits: Thanks for having us.
Leslie Ballas: I wanted to start by just reminding our audience that bladder cancer has a male predominance in terms of patients. It's about a three to one predominance of men to women. And we really wanted to talk today about women with bladder cancer.
And so I wanted to start by asking each of you-- and maybe, Dr. Smith, we can start with you. Is there a difference in your mind in treating men versus women with bladder cancer?
Armine Smith: Sure. And I'm so happy we're discussing this topic. I think gender disparities in bladder cancer are Dr. Hoffman and I are very passionate about. And they don't get nearly enough attention. So very glad to talk about this in public.
So yes, there is a difference in treating men versus women with bladder cancer on a few different fronts. There are biological and anatomical considerations. Obviously, women have distinct pelvic anatomy and hormonal influences and different exposures. All of these affect human presentation, surgical complexity, if nothing else, and the outcomes. If we were to look at, the radical cystectomy in women, it involves additional considerations, such as the pelvic organs that are reproductive in nature and sometimes do or do not need to be removed with the bladder.
There are also systemic biases. There are research gaps. Historically, bladder cancer has been studied and treated based on male-dominated data. Clinical trials, and not probably just in bladder cancer, have underrepresented women, meaning many standard protocols don't fully account for gender-specific needs. Treatment implications-- surgical planning, reconstruction options, functional outcomes-- may differ significantly for women, especially regarding sexual health and body image. So this same disease may require a different approach to preserve quality of life in female patients.
Leslie Ballas: How about in your practice, Dr. Hoffman? Are you noticing a difference in treating men versus women?
Jean Heather Hoffman-Censits: Yeah. So for your audience who's well versed in terms of the roles of a medical oncologist versus a urologist, they know that Dr. Smith is seeing everyone who walks in the door with a suspicion of a urological complaint. Most of the time, women with bladder cancer are presenting with the same symptoms that men have-- lower urinary tract symptoms, blood in the urine. They just have a really different story to tell.
When they finally do make it into my clinic with a diagnosis of muscle invasive or advanced bladder cancer, that they have seen multiple different specialists and been referred to sometimes a variety of different kinds of doctors for, ultimately, which is a urologic complaint. And it's the third or fourth doctor that they see that's finally a urologist that looks at the scope. I think that's one of the biggest things that we see in terms of presentation, especially in the later line setting. And one of the things that I think we're very sensitive to and, as Dr. Smith says, passionate about is kind of recognizing and hearing those stories from patients when they're coming into the office and then some of the other implications that go along with some of those delays that we see in diagnosis.
Leslie Ballas: And so are you two seeing that or finding that women present-- you explain that obviously they see a lot more providers before maybe they get to Dr. Smith and certainly before they get to you. But do you feel that women are presenting with later stage or more advanced disease, Dr. Smith?
Armine Smith: Yes, I'm so glad Dr. Hoffman kind of led you to this question because it's been shown consistently across multiple studies. Women are more likely to be diagnosed at the later stage. And why is that? It's because hematuria in women is a lot of times not taken quite as seriously or treated as a UTI. And they may see multiple doctors. And then this all leads to the delay in diagnosis to a urologist. There's also a general lack of awareness, which I believe it's getting better now, that bladder cancer can affect women at all.
Some other things that I think may be contributing are the women have a thinner bladder. And men do sometimes. And the anatomy of the bladder neck in women is a little bit different.
So a lot of the times, I see when the women undergo the biopsies of the tumors or the removal of the tumors from the bladder, the providers don't go deep enough. Or maybe there is just-- because of the thinness of the bladder, it's just easier for this to become more advanced quicker. That being said, just delayed diagnosis limits treatment options, negatively impact survival, we all know. So early interventions and then gender-based education for both providers and patients, those are all the things that we can do to help diagnose this earlier.
Leslie Ballas: I'm continuing to think about something that you both mentioned, which was the importance of sexual quality of life for these patients. And I'm wondering more broadly. But with that in mind, do women evaluate their treatment options differently than male patients? For example, if they have a muscle invasive bladder cancer and are looking at definitive therapy, do they tend to choose bladder preservation or cystectomy more often? Or is it not that sort of cut and dry to base it specifically on sex?
Armine Smith: And I'll start. And Dr. Hoffman hopefully can chime in and help with more advanced patient decisions. But yes, I think the bladder preservation has become more of a conversation now. When I just started practicing medicine or urology, which wasn't that long ago, bladder preservation was not as accepted.
And the other thing is these sexual conversations, where a lot more kind of pronounced when we saw male patients, not as much when we saw female patients. And I'm seeing some change towards it now, which makes me very happy. But again, there are all these things that make this decision making a little bit more difficult when we talk about women.
But now, at the current time and age, some women will value bladder preservation when it's oncologically safe. But decision making is layered and personal. Factors like incontinence, changes in sexual function, body image may weigh heavily on treatment preferences for both men and women.
I think some things that women have that I've noticed-- and I haven't noticed it quite as much in men, even though I can't put them all in the same kind of a boat. A lot more women are caregivers for their spouses, children, aging parents. And sometimes, that affects the ability to undergo these extensive treatments, including surgery and recovery. So that's my perspective.
Leslie Ballas: When we're talking about female sexual quality of life, do you find that perhaps part of the lack of addressing it with patients is that urologists who treat plenty of men with prostate cancer are used to assessing sexual quality of life, SHIM score, whereas with female patients, the questionnaires are not as ubiquitous, not as prevalent in general urology clinics? And so maybe urologists aren't-- it's not at the forefront of their mind to ask about female sexual quality of life.
Armine Smith: Yes, absolutely. If you talk to any urologist's office, you're very likely to run into a SHIM score posted somewhere. And if you go to a urologist office, even a specialized urologist that treats bladder cancers, treats women, it's unlikely that you would see a female sexual questionnaire posted anywhere. And I think that kind of takes away from the ability to even start a conversation. And hopefully, that will change over time. And we're all advocating for this.
Jean Heather Hoffman-Censits: And I think you mentioned, Dr. Smith, that you do feel like it's changing. And I do feel like there's definitely a groundswell of discussions around this. We've both been in this space for 10 or 15 years.
And you can feel that the discussions at major meetings and at patient advocacy meetings, like the BCAN, Bladder Cancer Advocacy Network. They have an annual meeting. And oftentimes, talking about female sexual health is top of mind and the topic of working groups and discussions.
So patients are bringing these issues to us. And I think that I'm proud that, as a discipline, I think we're all thinking about it more. And Dr. Smith is kind of out there in the forefront in terms of thinking about that from a research perspective. There's female sexual health. And then there's also fertility.
We're not seeing fertility issues as much. Because in bladder cancer, the average age of our patients, as you know, is in their 70s. But I think just like everybody else in colon cancer and other diseases, boy, are we seeing people earlier and earlier. And we don't know exactly what that's about. But we do recognize that that's another research question that we'll have to think about, not just sexual health but fertility in our patients.
Leslie Ballas: Dr. Smith, would you like to highlight the research that Dr. Hoffman alluded to? I'd love to hear about it.
Armine Smith: Yes, we have a few different research projects centering on women. One of them looks at female sexuality, ability to cope with the bladder cancer diagnosis based on the type of information the patient is kind of presented with and the longitudinal follow-up. And that's kind of one side of the story. The other one is the organ preservation for cystectomy and when is it safe to do that.
I'm so happy to report that, finally, American Urological Association put a little kind of blurb there that we can consider preserving organs in women during cystectomy. But again, that's kind of also a very understudied area. So we have a big trial looking at the organ preservation here.
Leslie Ballas: Tell me what was the impetus for the Greenberg Bladder Cancer Institute to form a Women's Bladder Cancer Program. That's not seen at a lot of institutions. And it's a really wonderful program to highlight.
Jean Heather Hoffman-Censits: So the Greenberg Bladder Cancer Institute is named for the benefactors, Stephanie and Irwin Greenberg, who are really passionate about bladder cancer and have generously made many contributions, including to Hopkins, and were instrumental in helping put our team together. Stephanie Greenberg will openly say that she spent a lot of time in urology waiting rooms being a caregiver and kind of noticed that this seemed like a male-centric space with a lot of female caregivers and male patients.
And as she was a caregiver kind of thinking about the journey that she was seeing, the person that she loved going through bladder cancer, she felt like, where are the women with bladder cancer? And what must their experience been? And this became a passion of hers.
And I think, independently, Dr. Smith and her training and her journey and me and my training and journey, both coming from different institutions and eventually landing at Hopkins, I think, also just became sensitive to it, in part from just being women and hearing the stories of women who, again, may have had a longer road to their diagnosis, may have felt unseen or unheard, or even, heaven forbid, felt like giving of their own medical history must have contributed to this delay.
As women, we're kind of not totally freaked out by seeing blood in the bathroom and won't likely to have urinary tract infections and potentially more likely to think this must be something else. And so there's a very different narrative in terms of when a lot of the women patients come into our office.
And so I think we all felt like there was definitely a need to think about this more and make space for those stories and those patients. And so I think we all came to that feeling together and then kind of wound up in the same space to really then take it to the next level and be able to really form a medical home and a support system for women with bladder cancer.
Armine Smith: That being said, I feel like we get validation over and over from patients that come in to see us when they see more women in the waiting room, female providers, or even programs that are kind of directed towards women with bladder cancer. It's amazing to see how much it's lagging elsewhere.
Jean Heather Hoffman-Censits: Yeah.
Leslie Ballas: Tell me, just since the three of us are women in bladder cancer as providers, do you feel that patients interact with you differently as a female provider, either women or male patients, for that matter?
Armine Smith: Yeah, for me, I think it varies. I've seen both. I've seen many women feel more comfortable discussing sensitive issues as intimacy, body image, fertility with a female provider. I think sometimes they might be more likely to open up when they feel seen and understood. And I think vice versa with males. But again, I've seen both sides of the coin with that.
Jean Heather Hoffman-Censits: I agree, although I haven't spent half of my life as a male provider. So I don't know the difference necessarily. But what I do know is that there are definitely patients who tell us, we came here because we looked around. And when you think about a female urologist and a female medical oncologist, both with expertise in bladder cancer, in the same room, that's not an event that happens very often.
So we're really proud that that's-- if it's a wish that our patients have, that it is a reality that we can provide, not only what we look like but the expertise that we can bring to the table. And I think that we can wholeheartedly say when female patients with bladder cancer come into our practice, you are not alone. You are not the only woman we're seeing today with bladder cancer.
You are part of this club you didn't necessarily sign up for. But you're amongst other women that share your story. And in fact, we have recognized that there's definitely a need for support.
And we have a tremendous patient and family services organization through the sibling practice that has really spearheaded and supported this women's bladder cancer ongoing kind of living support group that not only provides support but also a lot of information and education in different facets of not just bladder cancer care but cancer care and quality of life and survivorship issues.
Leslie Ballas: Thank you. Again, just want to thank both of you for sharing your expertise and for all that you're doing through the Women's Bladder Cancer Program and the research that we highlighted to provide female patients excellent quality of care. So thank you. And it was really a pleasure to talk with both of you.
Armine Smith: Thank you very much.
Jean Heather Hoffman-Censits: Thank you.
Leslie Ballas: Hi, my name is Leslie Ballas. And I am a radiation oncologist at Cedars-Sinai in Los Angeles who specializes in GU radiation oncology. I am honored to be joined today by Dr. Jeannie Hoffman-Censits, who is an associate professor of oncology and urology at Johns Hopkins University and the co-leader of the Women's Bladder Cancer Program as part of the Greenberg Bladder Cancer Institute.
I'm also honored to be joined by Dr. Armine Smith. She is an assistant professor of urology, Director of the Johns Hopkins Urologic Oncology Institute at Sibley Memorial Hospital, and also co-leader of the Women's Bladder Cancer Program as part of the Greenberg Bladder Cancer Institute. Thank you so much, both of you, for joining me today.
Jean Heather Hoffman-Censits: Thanks for having us.
Leslie Ballas: I wanted to start by just reminding our audience that bladder cancer has a male predominance in terms of patients. It's about a three to one predominance of men to women. And we really wanted to talk today about women with bladder cancer.
And so I wanted to start by asking each of you-- and maybe, Dr. Smith, we can start with you. Is there a difference in your mind in treating men versus women with bladder cancer?
Armine Smith: Sure. And I'm so happy we're discussing this topic. I think gender disparities in bladder cancer are Dr. Hoffman and I are very passionate about. And they don't get nearly enough attention. So very glad to talk about this in public.
So yes, there is a difference in treating men versus women with bladder cancer on a few different fronts. There are biological and anatomical considerations. Obviously, women have distinct pelvic anatomy and hormonal influences and different exposures. All of these affect human presentation, surgical complexity, if nothing else, and the outcomes. If we were to look at, the radical cystectomy in women, it involves additional considerations, such as the pelvic organs that are reproductive in nature and sometimes do or do not need to be removed with the bladder.
There are also systemic biases. There are research gaps. Historically, bladder cancer has been studied and treated based on male-dominated data. Clinical trials, and not probably just in bladder cancer, have underrepresented women, meaning many standard protocols don't fully account for gender-specific needs. Treatment implications-- surgical planning, reconstruction options, functional outcomes-- may differ significantly for women, especially regarding sexual health and body image. So this same disease may require a different approach to preserve quality of life in female patients.
Leslie Ballas: How about in your practice, Dr. Hoffman? Are you noticing a difference in treating men versus women?
Jean Heather Hoffman-Censits: Yeah. So for your audience who's well versed in terms of the roles of a medical oncologist versus a urologist, they know that Dr. Smith is seeing everyone who walks in the door with a suspicion of a urological complaint. Most of the time, women with bladder cancer are presenting with the same symptoms that men have-- lower urinary tract symptoms, blood in the urine. They just have a really different story to tell.
When they finally do make it into my clinic with a diagnosis of muscle invasive or advanced bladder cancer, that they have seen multiple different specialists and been referred to sometimes a variety of different kinds of doctors for, ultimately, which is a urologic complaint. And it's the third or fourth doctor that they see that's finally a urologist that looks at the scope. I think that's one of the biggest things that we see in terms of presentation, especially in the later line setting. And one of the things that I think we're very sensitive to and, as Dr. Smith says, passionate about is kind of recognizing and hearing those stories from patients when they're coming into the office and then some of the other implications that go along with some of those delays that we see in diagnosis.
Leslie Ballas: And so are you two seeing that or finding that women present-- you explain that obviously they see a lot more providers before maybe they get to Dr. Smith and certainly before they get to you. But do you feel that women are presenting with later stage or more advanced disease, Dr. Smith?
Armine Smith: Yes, I'm so glad Dr. Hoffman kind of led you to this question because it's been shown consistently across multiple studies. Women are more likely to be diagnosed at the later stage. And why is that? It's because hematuria in women is a lot of times not taken quite as seriously or treated as a UTI. And they may see multiple doctors. And then this all leads to the delay in diagnosis to a urologist. There's also a general lack of awareness, which I believe it's getting better now, that bladder cancer can affect women at all.
Some other things that I think may be contributing are the women have a thinner bladder. And men do sometimes. And the anatomy of the bladder neck in women is a little bit different.
So a lot of the times, I see when the women undergo the biopsies of the tumors or the removal of the tumors from the bladder, the providers don't go deep enough. Or maybe there is just-- because of the thinness of the bladder, it's just easier for this to become more advanced quicker. That being said, just delayed diagnosis limits treatment options, negatively impact survival, we all know. So early interventions and then gender-based education for both providers and patients, those are all the things that we can do to help diagnose this earlier.
Leslie Ballas: I'm continuing to think about something that you both mentioned, which was the importance of sexual quality of life for these patients. And I'm wondering more broadly. But with that in mind, do women evaluate their treatment options differently than male patients? For example, if they have a muscle invasive bladder cancer and are looking at definitive therapy, do they tend to choose bladder preservation or cystectomy more often? Or is it not that sort of cut and dry to base it specifically on sex?
Armine Smith: And I'll start. And Dr. Hoffman hopefully can chime in and help with more advanced patient decisions. But yes, I think the bladder preservation has become more of a conversation now. When I just started practicing medicine or urology, which wasn't that long ago, bladder preservation was not as accepted.
And the other thing is these sexual conversations, where a lot more kind of pronounced when we saw male patients, not as much when we saw female patients. And I'm seeing some change towards it now, which makes me very happy. But again, there are all these things that make this decision making a little bit more difficult when we talk about women.
But now, at the current time and age, some women will value bladder preservation when it's oncologically safe. But decision making is layered and personal. Factors like incontinence, changes in sexual function, body image may weigh heavily on treatment preferences for both men and women.
I think some things that women have that I've noticed-- and I haven't noticed it quite as much in men, even though I can't put them all in the same kind of a boat. A lot more women are caregivers for their spouses, children, aging parents. And sometimes, that affects the ability to undergo these extensive treatments, including surgery and recovery. So that's my perspective.
Leslie Ballas: When we're talking about female sexual quality of life, do you find that perhaps part of the lack of addressing it with patients is that urologists who treat plenty of men with prostate cancer are used to assessing sexual quality of life, SHIM score, whereas with female patients, the questionnaires are not as ubiquitous, not as prevalent in general urology clinics? And so maybe urologists aren't-- it's not at the forefront of their mind to ask about female sexual quality of life.
Armine Smith: Yes, absolutely. If you talk to any urologist's office, you're very likely to run into a SHIM score posted somewhere. And if you go to a urologist office, even a specialized urologist that treats bladder cancers, treats women, it's unlikely that you would see a female sexual questionnaire posted anywhere. And I think that kind of takes away from the ability to even start a conversation. And hopefully, that will change over time. And we're all advocating for this.
Jean Heather Hoffman-Censits: And I think you mentioned, Dr. Smith, that you do feel like it's changing. And I do feel like there's definitely a groundswell of discussions around this. We've both been in this space for 10 or 15 years.
And you can feel that the discussions at major meetings and at patient advocacy meetings, like the BCAN, Bladder Cancer Advocacy Network. They have an annual meeting. And oftentimes, talking about female sexual health is top of mind and the topic of working groups and discussions.
So patients are bringing these issues to us. And I think that I'm proud that, as a discipline, I think we're all thinking about it more. And Dr. Smith is kind of out there in the forefront in terms of thinking about that from a research perspective. There's female sexual health. And then there's also fertility.
We're not seeing fertility issues as much. Because in bladder cancer, the average age of our patients, as you know, is in their 70s. But I think just like everybody else in colon cancer and other diseases, boy, are we seeing people earlier and earlier. And we don't know exactly what that's about. But we do recognize that that's another research question that we'll have to think about, not just sexual health but fertility in our patients.
Leslie Ballas: Dr. Smith, would you like to highlight the research that Dr. Hoffman alluded to? I'd love to hear about it.
Armine Smith: Yes, we have a few different research projects centering on women. One of them looks at female sexuality, ability to cope with the bladder cancer diagnosis based on the type of information the patient is kind of presented with and the longitudinal follow-up. And that's kind of one side of the story. The other one is the organ preservation for cystectomy and when is it safe to do that.
I'm so happy to report that, finally, American Urological Association put a little kind of blurb there that we can consider preserving organs in women during cystectomy. But again, that's kind of also a very understudied area. So we have a big trial looking at the organ preservation here.
Leslie Ballas: Tell me what was the impetus for the Greenberg Bladder Cancer Institute to form a Women's Bladder Cancer Program. That's not seen at a lot of institutions. And it's a really wonderful program to highlight.
Jean Heather Hoffman-Censits: So the Greenberg Bladder Cancer Institute is named for the benefactors, Stephanie and Irwin Greenberg, who are really passionate about bladder cancer and have generously made many contributions, including to Hopkins, and were instrumental in helping put our team together. Stephanie Greenberg will openly say that she spent a lot of time in urology waiting rooms being a caregiver and kind of noticed that this seemed like a male-centric space with a lot of female caregivers and male patients.
And as she was a caregiver kind of thinking about the journey that she was seeing, the person that she loved going through bladder cancer, she felt like, where are the women with bladder cancer? And what must their experience been? And this became a passion of hers.
And I think, independently, Dr. Smith and her training and her journey and me and my training and journey, both coming from different institutions and eventually landing at Hopkins, I think, also just became sensitive to it, in part from just being women and hearing the stories of women who, again, may have had a longer road to their diagnosis, may have felt unseen or unheard, or even, heaven forbid, felt like giving of their own medical history must have contributed to this delay.
As women, we're kind of not totally freaked out by seeing blood in the bathroom and won't likely to have urinary tract infections and potentially more likely to think this must be something else. And so there's a very different narrative in terms of when a lot of the women patients come into our office.
And so I think we all felt like there was definitely a need to think about this more and make space for those stories and those patients. And so I think we all came to that feeling together and then kind of wound up in the same space to really then take it to the next level and be able to really form a medical home and a support system for women with bladder cancer.
Armine Smith: That being said, I feel like we get validation over and over from patients that come in to see us when they see more women in the waiting room, female providers, or even programs that are kind of directed towards women with bladder cancer. It's amazing to see how much it's lagging elsewhere.
Jean Heather Hoffman-Censits: Yeah.
Leslie Ballas: Tell me, just since the three of us are women in bladder cancer as providers, do you feel that patients interact with you differently as a female provider, either women or male patients, for that matter?
Armine Smith: Yeah, for me, I think it varies. I've seen both. I've seen many women feel more comfortable discussing sensitive issues as intimacy, body image, fertility with a female provider. I think sometimes they might be more likely to open up when they feel seen and understood. And I think vice versa with males. But again, I've seen both sides of the coin with that.
Jean Heather Hoffman-Censits: I agree, although I haven't spent half of my life as a male provider. So I don't know the difference necessarily. But what I do know is that there are definitely patients who tell us, we came here because we looked around. And when you think about a female urologist and a female medical oncologist, both with expertise in bladder cancer, in the same room, that's not an event that happens very often.
So we're really proud that that's-- if it's a wish that our patients have, that it is a reality that we can provide, not only what we look like but the expertise that we can bring to the table. And I think that we can wholeheartedly say when female patients with bladder cancer come into our practice, you are not alone. You are not the only woman we're seeing today with bladder cancer.
You are part of this club you didn't necessarily sign up for. But you're amongst other women that share your story. And in fact, we have recognized that there's definitely a need for support.
And we have a tremendous patient and family services organization through the sibling practice that has really spearheaded and supported this women's bladder cancer ongoing kind of living support group that not only provides support but also a lot of information and education in different facets of not just bladder cancer care but cancer care and quality of life and survivorship issues.
Leslie Ballas: Thank you. Again, just want to thank both of you for sharing your expertise and for all that you're doing through the Women's Bladder Cancer Program and the research that we highlighted to provide female patients excellent quality of care. So thank you. And it was really a pleasure to talk with both of you.
Armine Smith: Thank you very much.
Jean Heather Hoffman-Censits: Thank you.