The Evolving Treatment Landscape of Low-grade Upper Tract Urothelial Carcinoma

EP. 4A: The Importance of Patient Education When Selecting Treatments for Low-grade UTUC

In the fourth interview of the series, Armine K. Smith, MD, from Sibley Memorial Hospital in Washington DC highlights considerations when discussing LG UTUC treatment options with patients including key points about response rates, adverse effects and long-term consequences, treatment availability, and insurance challenges.

Our historic treatments of UTUCs have been largely extirpative in nature. As such, it led to a loss of kidney or part of the upper tract, such as a segment of the ureter. As our technology has progressed, we have largely accepted the newer treatments—such as ablative treatments, keeping the kidney in place, and installations of the upper tracts—in the appropriate selected patients in lieu of radical surgery. When given the choice of losing the kidney vs not, patients tend to pick the latter, because when we keep the kidney, we preserve the renal function. It helps us to avoid more radical, bigger surgery, and not all the patients are good candidates for [those] types of surgeries.

It's our responsibility as providers to ensure that patients have appropriate counseling on the nature of the treatments we offer. Patient understanding of the treatments vary to a very large degree. Some have never heard of treatments before, and some come in with a preprinted stack of articles about their disease. Some patients want the provider to take the lead in deciding what treatment is appropriate for them, and others want a more balanced discussion. Our mission is to educate our patients about what's available and to find the right approach for each and every one of them.

Of course, response rate to the treatment is very meaningful to the patients, and [it affects] provider-patient discussions. Patients want to have the odds of treatment in favor of beating their cancer. [With] that being said, there is no cookie-cutter approach in medicine, and these numbers need to be tailored to the scenario.

In urology in general, we have moved further into the [use of] multimodal treatments. These discussions have become more of the norm in various urologic cancer scenarios. Most of the people want to have a quick fix to their cancer. Some are terrified of the surgery, [and] others are just completely terrified of the word “chemotherapy,” so an appropriate education has to be given for these scenarios. After all is said is done, in general, the combination of surgical and nonsurgical treatments is perfectly acceptable [to] the patients.

This speaks of the thoroughness of the discussion about the treatments to the patients. They want to be well-informed about the potential short-term [and] long-term [AEs] and [the] consequences of the treatments. These have to be weighed [against] the benefits and alternatives of the treatments. As long as the patients are given all the information upfront, and they’ve had the appropriate discussion, they’re able to make an informed decision, and this includes the willingness to tolerate these [AEs] and consequences.

When we take the patient, we have to consider all kinds of circumstances of their ability to receive the treatment, including their ability to pay for it and their ability to get to the treatments, [which includes] transportation and things of [that] nature.

[One of] the limitations of the treatments, obviously, is the knowledge and the skill of the provider. It also needs to be coupled with the availability of the treatments in the specific location where these would take place. This has to do with the formulary of the pharmacy, the equipment in the practice, and the hospital. It would be great if, anywhere in the world, patients would have access to the latest treatment options, including academic vs community [settings] and urban vs rural areas. Hopefully, we're moving that way.

Transcript has been edited for clarity.