Benefits of Surgery in Older Adults with Metastatic Urothelial Carcinoma Evaluated Using Largest Dataset of its Kind

Bladder_FBUrothelial carcinoma is the most common type of bladder cancer, also affecting other parts of the urinary system. It is an aggressive disease and its treatment remains challenging for clinicians. Currently, each year there are nearly 80,000 new cases of urothelial cancer and approximately 16,000 deaths from the disease, according to the American Cancer Society. Unfortunately, there are limited therapeutic options for those with advanced urothelial carcinoma especially after the disease spreads to other distant organs (metastasis). Even with platinum-based chemotherapy and the introduction of immunotherapy, median overall survival is poor, and a five-year survival is only 15%.

The idea of metastasectomy (surgical removal of metastatic tumors) has been proven to be an established option in the treatment of patients with other solid tumors, however, little is known regarding the benefit and safety of this type of surgery for urothelial carcinoma patients because previous studies were mostly from single institutions and limited by small sample size.

Drs. Bishoy Faltas, Scott Tagawa, Jim Hu, along with others at Weill Cornell Medicine and NewYork-Presbyterian Hospital, partnered with the Center for Health Policy and Outcomes and Memorial Sloan Kettering Cancer Center to address this very question and their research has now been published in Urologic Oncology: Seminars and Original Investigations. Their goal was to examine the use and outcomes of surgery in older patients with urothelial carcinoma in a large population-based dataset. To do this, clinicians conducted a SEER-Medicare study. SEER is a database run by the National Institutes of Health (NIH) that collects large population-based data that provide detailed information about Medicare beneficiaries with cancer. The research was analyzed based on the billing codes the physician’s offices used when submitting insurance claims.

Using this data, clinicians found 70,648 urothelial carcinoma patients and from those, they identified 497 patients who had at least one surgery to remove a metastatic lesion during a median follow-up of 40 months. The median overall survival after the first surgery was 19 months. In this selected patient population, over a third of patients were alive at three years. The median length of stay after surgery was seven days with 10% of patients having at least one complication within 30 days of discharge.

Close-up of gloved hands passing the surgical scissors“It would be very difficult to conduct a randomized clinical trial testing surgery versus no surgery in those with urothelial carcinoma, so reviewing a large dataset retroactively is the next best thing,” says Dr. Bishoy Faltas, Assistant Professor and medical oncologist at Weill Cornell Medicine’s Genitourinary Oncology Program. “Our study shows that in well-selected patients with urothelial carcinoma with a reasonable life expectancy, resection of metastatic lesions is safe and associated with long-term survival and potential cures,” says Dr. Faltas.

What are Other Benefits of Surgery?

Aside from the fact that surgery can prolong life for those with urothelial carcinoma, there are other benefits as well. One of the benefits is enabling the testing of tissue that is removed. Studying this tissue allows clinicians to continue performing precision medicine and treating the individual, not the disease. As described in a previous research study conducted by Dr. Bishoy Faltas titled, “Clonal Evolution of Chemotherapy-Resistant Urothelial Carcinoma” published in Nature Genetics, it has been proven that tumors change and undergo clonal evolution over time especially in metastases after chemotherapy.

“Understanding the evolution of urothelial carcinoma is a central biological question and one that we can only truly begin to understand by testing tissue samples from patients at various periods throughout their treatment,” says Dr. Faltas.

Another potential benefit of surgery is the cost implication. With drug prices continuing to rise, depending on insurance carriers, there is the potential that surgery may be less costly than some of the long-term medications associated with treatment for urothelial cancer. Cost implications of course vary for each patient; however, it is one of the factors along with many others that should be addressed and discussed with healthcare teams.

“There is a lot more work to be done to help treat patients with urothelial cancer, however with the dataset we’ve compiled through our latest study, we’re able to glean the potential benefits of metastasectomy in older adults with urothelial cancer, which could lead to prolonged life and potential cures.”

Prostate Cancer Education Seminar Presented as Part of WCM/NYP Health and Wellness Fall Series

Each fall, Weill Cornell Medicine (WCM) and NewYork-Presbyterian (NYP) host a health and wellness seminar series – one seminar every week for a month – where physicians educate the local community about different types of health issues.

Tagawa and Nanus Prostate TalkLast week, Dr. David Nanus, professor of medicine and urology at Weill Cornell Medicine and Dr. Scott Tagawa, medical oncologist and Director of the Weill Cornell Medicine Genitourinary (GU) Oncology Program, presented to and educated people in the local community about prostate cancer. Their presentation was titled, “Your Guide to Prostate Health and What to Know About the Leading Cancer in Men.” Following the presentation, all attendees were invited to ask the physicians questions.

Nanus Prostate Talk
Some of the key topics from Dr. Nanus and Dr. Tagawa’s presentations included the common risk factors for prostate cancer, the importance of screening, the latest treatments and research, as well as utilizing the precision medicine approach.

 

Key highlights from their presentations are outlined below.

 Prostate Cancer Risk Factors

Prostate cancer risk factors include age, ethnicity and inherited genetic conditions. For example, those diagnosed with prostate cancer are predominantly older men. Additionally, new data points towards a surprisingly high percentage with inherited cancer genes. Those with genetic conditions such as BRCA 1 or BRCA 2 or those with prostate cancer in their family history are also more likely to be diagnosed with the disease.

Early Detection and Screening

Dr. Nanus and Dr. Tagawa highlighted the importance of screening and early detection by referencing the recently-updated National Comprehensive Cancer Network (NCCN) prostate cancer screening guidelines. Despite ongoing debate over the value of prostate cancer screening, this past September, NCCN’s guidelines suggest that screening canTagawa Prostate Talk indeed reduce a man’s risk of dying from the disease and that prostate-specific antigen (PSA) testing and digital rectal examination (DRE) should be done. Newer tests are also available to assist in counseling about biopsies and targeted biopsies are now offered at selected centers. Dr. Scott Tagawa addressed the importance of the “shared decision-making” model when it comes to prostate cancer screening. For example, men considering screening are encouraged to discuss with their healthcare team and family members the pros and cons of getting screened and what the best course of action would be if the results lead to a diagnosis.

Treatments

The presentation also addressed the different treatment approaches. As a first step, the most important factor in choosing the best way to treat prostate cancer is knowing what stage the cancer is in. Prostate cancer has been traditionally staged and “risk-stratified” based on the extent of the cancer (using T, N, and M categories) and the PSA level and Gleason score at the time of diagnosis.

We now have additional molecular tests to add prognostic value. In certain circumstances, these tests assist in the decision for “radical treatment” which has been traditionally performed with surgery and/or radiation versus active surveillance (which entails regular monitoring visits in addition to repeat imaging/biopsy). It is important to note that most men diagnosed with prostate cancer, including some that have recurrence after surgery or radiation, will never die of the disease.

Novel molecular imaging techniques have assisted in telling physicians and researchers about the location of previously unseen cancer and also providing information about the biology of certain tumors. A number of therapeutic advances have occurred over the last several years resulting in men with incurable cancer living longer with a better quality of life.

Precision Medicine

Dr. Tagawa emphasized the great strides and therapeutic advances over the years in prostate cancer treatments, but that more work still needs to be done. There are now many options for therapies that make men live longer while also making them feel better. One of the reasons for this advancement is the use of precision medicine, which means that physicians are treating each individual based on their own genetic makeup without using a “one size fits all” type of approach. A key factor in making this method successful is through clinical trials. We often interrogate a patient’s tumor from surgery or an image-guided needle biopsy. In addition, liquid biopsies are now increasingly valuable.

View this FOX 5 clip featuring Dr. David Nanus and Dr. Scott Tagawa with their patient, Alex Sarmiento, who was diagnosed with prostate cancer and tested with a liquid biopsy.

Research

Data shows that most adults with cancer do not participate in clinical trials. It is through clinical trials that new treatments and combinations of treatments can be identified. Clinical trials pave the way toward further scientific advances that could potentially help to find a cure for prostate cancer, and other cancers as well. These trials also have the ability to offer therapies to patients that they otherwise would not have access to. The most common reason that patients do not enroll in clinical trials is because they were not told that this was an option. We suggest asking your physician about access to clinical trials at each stage of the disease and/or seeking out centers that have trials available.

Weill Cornell Medicine and NewYork-Presbyterian offers many prostate cancer-specific trials that you can search for here.

Top 5 Diet and Cancer Myths

By Shayne Robinson, RD, CSO, CDN and Jackie Topol, MS, RD, CSO, CDN

RefrigeratorWe know that there is a great deal of conflicting information about nutrition that patients may receive from various sources. As Registered Dietitians who are board certified in oncology nutrition, we are here to clear up some of the confusion. Here are some of the most common nutrition myths we hear from patients:

Myth # 1 – Sugar feeds cancer.

Within the body, all carbohydrates break down to sugar which both healthy and cancer cells use for fuel. Research shows that the body responds to a high sugar intake by making more insulin and related growth factors, which influence cancer cell growth. However insulin levels also depend on genetic factors, physical activity, BMI (body mass index), metabolic syndrome (a group of medical conditions linked to insulin resistance) and the type of sugar you eat. Therefore just avoiding sugar is not the right plan for everybody. It’s important to maintain healthy blood sugar and insulin levels during cancer treatment and in general. In prostate cancer, hormonal therapy is associated with weight gain and the way the body processes sugar, so it’s important to be mindful of this when making dietary choices. Ongoing research is looking to target some of these pathways.

The key question to ask is “How much and what type of carbohydrates should I eat?” A Registered Dietitian who is specially certified in oncology nutrition (RD, CSO) can help you design a well-balanced eating plan that best fits your needs.

Reference: https://www.oncologynutrition.org/erfc/healthy-nutrition-now/sugar-and-cancer/

Myth #2 – I need to avoid raw fruits and vegetables.

Raw fruits and vegetables that have been washed can be eaten while you are receiving chemotherapy and/or radiation. If you have a very low neutrophil count (known as “neutropenia”) or a recent bone marrow transplant, your doctor or dietitian may recommend a low microbial diet. On the low microbial diet, you can eat most raw vegetables and most raw fruits that have a smooth skin or a thick peel. The fruits and vegetables we advise not consuming on the low microbial diet are the ones you cannot wash thoroughly or those that may have mold such as raw mushrooms, sprouts, strawberries, blueberries, raspberries, grapes, peaches, and plums. In the current era of treatment for genitourinary cancers, most targeted therapies do not suppress the immune system or require a low microbial diet. Not all cancer patients will have to follow these guidelines since they are specifically for leukemia and bone marrow transplant patients. If you are not sure whether you should be following a low microbial diet or how long you should follow it for, we encourage you to speak to your doctor or dietitian. Additionally, there are certain oral treatments for kidney cancer that are linked with gastrointestinal side effects such as diarrhea. There are ways to include fruits and vegetables in the diet while taking these factors into account. There are many health benefits that go hand-in-hand with eating fruits and vegetables, so make sure to include them in your diet! If you are concerned that you may not be meeting your nutritional needs, you can make an appointment with one of our dietitians who can help.

Reference: https://www.foodsafety.gov/risk/cancer/index.html and NewYork-Presbyterian’s “Guidelines for the Low Microbial Diet”

Myth # 3 –  Certain foods will increase my white blood cell count.

Chemotherapy drugs, radiation therapy, and cancers of the blood and bone marrow can damage bone marrow and lower white blood cell counts. These cells recover with time.  Blood counts are low because the bone marrow isn’t working properly, not because the body lacks the nutrients to make blood cells.

No specific foods or nutrients increase production of white blood cells, but if you have low blood counts it is very important that you eat well because a well-nourished person recovers quicker from treatment than a malnourished person. Specific foods or nutrients won’t speed up the recovery of your bone marrow, but you do want to eat well so that when your bone marrow recovers all the nutrients that are the building blocks for cells are available for your body to make the white blood cells. A Registered Dietitian specially certified in oncology nutrition (RD CSO) can help you ensure you are eating well and in turn optimize your white blood counts.

Reference: http://www.oncologynutrition.org/erfc/eating-well-when-unwell/white-blood-count-diet/

Myth # 4 – Cancer survivors must eat only organic produce.

Organically grown produce have lower pesticide residues and synthetic (man-made) food additives, but following an organic diet does not guarantee a healthy diet. In fact, avoiding conventionally grown produce may eliminate some healthy food options. In a study looking at 50 years of scientific articles about the nutrient content of organic and conventionally grown foods, the researchers concluded that organic and conventionally grown foods are not significantly different in their nutrient content. There have not been any direct studies on humans to show that organically grown produce can prevent cancer or other diseases any more effectively than conventionally grown foods.

What does this mean in terms of your grocery list? If you go into the market to buy a fresh organic apple, and they only have conventionally grown produce, don’t walk out with a bag of processed organic chips or cookies… A conventionally grown apple is a better choice than organic processed foods.

References:  www.mayoclinic.com/health/organic-food/NU00255
www.foodnews.org  (from the Environmental Working Group)

Myth # 5 – I need to avoid soy foods.

It is safe to eat soy! Research has shown that moderate consumption is safe for women with a history of breast cancer, including women previously diagnosed with estrogen receptor positive breast cancer, and that soy consumption may even decrease the likelihood of breast cancer recurrence. Confusion about soy arises from the term “phytoestrogens.” Some soy nutrients have a chemical structure that look a bit like the estrogen found in a woman’s body. This is where the term phytoestrogen originated. However, phytoestrogens are not the same thing as female estrogens. Soy foods do not contain estrogen. Men with prostate cancer who are taking hormonal therapies also commonly inquire about the impact of eating soy, but again, soy is okay to eat. If you consume soy products, we recommend choosing whole soy foods such as such as soymilk, tofu, tempeh, edamame, soy nuts, and miso. You can have up to two servings per day.  One serving would be 1 cup of soymilk; ½ cup of tofu, tempeh, or edamame; ¼ cup of soy nuts; or 1 tablespoon of miso paste. It is best to get soy directly from foods sources; we do not recommend taking a soy isoflavones supplement.

References: http://www.oncologynutrition.org/erfc/hot-topics/soy-and-breast-cancer/; http://www.oncologynutrition.org/erfc/hot-topics/soy-and-hormone-related-cancers/

Nothing replaces the individualized counseling you will receive from working with an RD on a one-on-one basis. We’re here to help you.

shayne Robinson_head shot 2Shayne Robinson RD, CSO, CDN is an oncology dietitian at New York-Presbyterian.  To make an appointment, call the Outpatient Nutrition Practice at (212) 746-0838 (physician referral required). 

Jackie Topol RD_Headshot_jgt9003
Jackie Topol, MS, RD, CSO, CDN is an integrative dietitian at
Integrative Health at NYP – Weill Cornell Medicine, located at 211 East 80th Street. To make an appointment, please call: 646-962-8690.