The Evolving Treatment Landscape of Low-grade Upper Tract Urothelial Carcinoma
In this companion article, Armine K. Smith, MD, reflects on the role of kidney-sparing approaches for LG UTUC and emphasizes the importance of patient-provider communication when making treatment decisions.
In this Urology Medical Perspectives series, “The Evolving Treatment Landscape of Low-grade Upper Tract Urothelial Carcinoma (LG UTUC),” experts in the management of urologic malignancies share their perspectives on the evolving treatment landscape for affected patients. Historic treatments have frequently involved the removal of affected tissue; however, experts have highlighted the continually evolving role of alternative kidney-sparing treatment approaches. In the interview ahead, Armine K. Smith, MD, from Sibley Memorial Hospital in Washington, DC; and an assistant clinical professor of urology at Johns Hopkins University School of Medicine in Baltimore, Maryland; reflects on key considerations when discussing available treatment options with patients. Among points examined were development of an effective dialogue on about response rates, short- and long-term consequences of treatment, and challenges related to insurance and treatment availability.
Urology Times®: When discussing treatment options with patients diagnosed with LG UTUC, do patients typically express reservations [about using] historic treatments vs more recent advancements? What level of understanding do patients express about the pros and cons of each treatment option?
SMITH: 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.
Urology Times®: How meaningful are response rate data to your patients? Do they influence their decision-making when selecting among available treatment options?
SMITH: 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. For example, [as] a radical example, let's say [that] a patient already has a poor baseline renal function, and a loss of renal unit [would] put them on dialysis. In this scenario, low response may be more acceptable to the patient. But this is more of [an] extreme scenario, so patients tend to favor higher rates for the response.
Urology Times®: What are patients' typical reactions to this prospect of combining surgical and nonsurgical approaches? How do patients usually respond when presented with the adverse effects (AEs) and long-term consequences of the available treatment options?
SMITH: 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.
Urology Times®: Can you share some of the concerns that patients may share with you regarding insurance coverage and other obstacles to treatment?
SMITH: 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. All [of] the treatments usually have to go through preauthorization before the patients are able to receive them. I know we are able to work with the system and work with a lot of the insurances to make this happen. This is true of all the treatments, not 1 in particular.
Urology Times®: Are the different treatment options that are approved for LG UTUC readily available to all patients, regardless of the treatment setting?
SMITH: [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.