Improving Outcomes for Stage I Bladder Cancer

Paul Crispen, MD, defines recurrence rates in stage I bladder cancer. He characterizes established methods to decrease disease recurrence and helps us to recognize barriers to implementing methods that would improve outcomes.
Improving Outcomes for Stage I Bladder Cancer
Paul Crispen, MD
Paul Crispen, MD is an Associate Professor, Urology, University of Florida College of Medicine. 

Learn more about Paul Crispen, MD

Melanie Cole (Host): Welcome to UF Health Med Ed Cast with UF Health Shands Hospital. I'm Melanie Cole and today, we're talking about improving outcomes for stage I bladder cancer. Joining me is Dr. Paul Crispen. He's an Associate Professor of Urology at the University of Florida College of Medicine. Dr. Crispen, it's a pleasure to have you join us today. Tell us a little bit about bladder cancer and recurrence rates in stage I bladder cancer, specifically.

Paul Crispen, MD (Guest): Certainly. And so, overall they're going to be 80,000 new cases of bladder cancer per year in the United States. Most of these are going to be diagnosed in older patients. The average age of diagnosis across the country is 73 years and there was a about a 3:1 ratio of males being diagnosed compared to females with this. And there's a number of reasons why it's more common in males, including increased use of tobacco, potentially metabolism of carcinogens and different sex steroids. What we do know though is no matter what age you're diagnosed, or if you're a male or female, the majority of patients diagnosed with bladder cancer are going to have stage I bladder cancer, and that's going to represent about 70 to 80 patients of the new diagnoses per year.

For patients with stage I bladder cancer, the chance of the cancer coming back, after the initial diagnosis ranges from 30% up to 80%. So there's a big range there. And the timing of the recurrence can differ dramatically with the type of cancer that's diagnosed and the type of stage I, as there's different types of risk categories of stage I bladder cancer at the time of diagnosis.

Host: So interesting. Dr. Crispen, thank you for that answer. So, tell us about UF Health Shands Hospital's approach to treating patients with stage I bladder cancer. How's it unique? Tell us what you're doing there.

Dr. Crispen: So, we put a great deal of importance on optimizing patients from the onset of diagnosis moving forward. There's a lot of things that we do on a routine basis that I think helps to improve the outcomes of our patients and where we're really trying to decrease the chance of recurrence in our patients on a daily basis. There's a number of things we're doing. The first is avoiding the diagnosis being based upon a biopsy alone. When a patient first comes to see us with a bladder tumor, we want to do more than just take a piece of that tumor out. We want to get a good resection in the operating room where we're removing the entire bladder tumor, any associated abnormalities around it and getting a good look around the bladder to make sure we're not missing anything.

And now that can be difficult to do. There are techniques that are available such as using something called blue light cystoscopy, that we use here at UF Shands Hospital in detecting these tumors. And the blue light cystoscopy differs from traditional cystoscopy, as we put a medicine in the bladder about an hour before the procedure, and this medicine will actually have normal tissue, have a blue color to it, and the tumors light up pink, and this can really help us find other small areas that we may miss with traditional white light cystoscopy.

It does involve an additional procedure to put the medicine in the bladder, but we know from randomized trials that using this type of approach with the blue light cystoscopy can increase the detection rate of stage I tumors up to 40% and has led to a decrease in cancer recurrence in patients by up to 33%. And beyond this, beyond the use of blue light cystoscopy, we also advocate for the use of immediate chemotherapy following the resection of the bladder tumor. And so the chemotherapy that we advocate, isn't the traditional chemotherapy that patients often think of, or providers often think of where we give the chemotherapy in the vein. This is instead a single dose of chemotherapy that we would instill into the bladder while the patient's in the operating room and then drain it.

So, it's a one-time treatment that's done the same day of the procedure. However, by doing that, we can further reduce the risk of cancer recurrence by about 34%. And lastly, something that we're doing routinely at UF Shands Hospital is following up with the recommended, repeat resections in patients that have certain types of stage I tumor that put them at a higher risk of recurrence. And that's something that nationally may only occur in about a third of patients, but our rate of doing these repeat resections when indicated is over 90%.

Host: Wow. That's fascinating. And thank you for characterizing those methods to decrease disease recurrence. And now what are some of the barriers Dr. Crispen to implementing some of these methods and even after the fact for these patients, which you stated were, you know, on the average more males, get this. Tell us about some of these barriers that could improve outcomes.

Dr. Crispen: So, some of the barriers, thankfully we don't have some of these barriers at the UF Shands Hospital is the access to the blue light cystoscopy. That's not widely practiced in a lot of urology centers, in the state or across the country, because it does require specialized medications and equipment to provide that care. Also the routine use of the chemotherapy, isn't always available in every hospital. But we've developed a system here where we can guarantee access to that chemotherapy, no matter where we do the procedure in our hospital. Following those initial resections, patients can have a lot of barriers though to receiving them the next step in care, the next step in the treatment of their stage I bladder cancer.

And that's not something that's unique to any one center. That's a national barrier. And that is too, receiving a medication called BCG and that BCG medication is an immunotherapy that's been used to reduce the risk of cancer recurrence in patients with stage I bladder cancer. We've been using it for over 30 years now. Unfortunately, there is limited ability to produce that medication in the United States with only one FDA approved form of BCG currently, and many patients over the last several years have been unable to get BCG because of this national shortage. And again, that continues to be ongoing and there's very aggressive, active plans to try to overcome that.

One way that we have been successful in overcoming that barrier at UF Shands Hospital is by offering our patients clinical trials where we can get guaranteed access to the BCG. Having that clinical trial open during the past two and a half years, has allowed me to give more patients BCG that otherwise would not receive it. And so then the other amount of BCG that I receive outside of this clinical trial, I've been able to provide the patients who would not qualify for the study. And so I think that's probably the largest barrier for the treatment of patients with stage I bladder cancer, nationally.

Host: While you're talking about clinical trials, is there any interesting research you'd like to let other providers know, maybe genetics or epigenetics? You mentioned briefly immuno oncology. Tell us a little bit about what's exciting in your field and any future research you see coming down the pike.

Dr. Crispen: Certainly. And so when we're talking about improving the care of stage I bladder cancer, one of the most critical needs is improving the care of patients with stage I bladder cancer who no longer respond to BCG therapy. And there've been tremendous breakthroughs through research conducted nationally and through research conducted here at UF Shands Hospital and improving the care of those patients. Right now, there's one particular medication that we've been involved with the clinical trial, looking at using an adenovirus, the common cold virus to be put into bladders to help fight BCG refractory stage I bladder cancer. And that medication is currently undergoing FDA review. And hopefully that could be available not only to our patients here, but across the country, in the near future.

And so everyone, I think who treats stage I bladder cancer is very excited about that possibility. Despite the success of that trial, we're always looking for the next step. And so what happens to patients who don't respond to that therapy? And we've got ongoing trials now at the UF Health Shands Hospital that are addressing that need, and we'll continue to develop those in the future.

Host: Such an interesting topic, Dr. Crispen, as we wrap up, what would you like other providers to know about optimizing effective treatment and bladder health among their patients and the importance of a multidisciplinary approach for these patients?

Dr. Crispen: So, I think one of the biggest things that all providers could improve on is getting patients diagnosed early. There's no standardized screening program for bladder cancer like there are for other cancers like breast cancer or colorectal cancer. And so we often rely on patients seeing their primary care providers and being referred to us to make the diagnosis of bladder cancer. And often we'll see patients coming in late, because maybe some of the signs and symptoms of bladder cancer were overlooked or the patients had blood in the urine and it was attributed to a urinary tract infection where it was actually coming from a bladder cancer. And so I think one of the best things we could do as a healthcare community to improve bladder cancer outcomes, is to do a better job, maybe of recognizing the signs of bladder cancer, to make the diagnosis as early as possible to help drive down the recurrence rates.

Host: What great information, such an informative episode, Dr. Crispen. Thank you so much for joining us and sharing your incredible expertise today. To refer your patient or to listen to more podcasts from our experts, you can always visit for more information. That concludes today's episode of UF Health Med Ed Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.