Attacking Bladder Cancer: Improving Efficiency, Clinical Management and Research

Historically, radical cystectomy patients faced long hospital stays and complications that could lead to readmissions. “Cystectomy patients are the sickest patients we care for,” says Glickman Urological & Kidney Institute urologist Georges-Pascal Haber, MD, PhD.

With this in mind, the perioperative management of patients undergoing radical cystectomy has undergone a radical change at Cleveland Clinic.

Dr. Haber and colleagues have overhauled their approach to cystectomy care from presurgical patient education and preparation to recovery and follow-up. The result? Length of stay dropped by 29 percent, costs decreased by 14 percent, postsurgery emergency room visits dropped 40 percent and readmissions went down by 39 percent.

ERAP instituted

Known as enhanced recovery after procedures (ERAP), these changes reflect a multidisciplinary, data-driven approach. The program brings together anesthesiologists, surgeons, clinical and administrative fellows, residents, nurses and administrators. They have created a patient education guide, renounced bowel prep and fasting before surgery, reduced the amount of opioids and fluids given to patients (lowering the risk for developing an ileus) and did away with nasogastric tubes and encourage patients to ambulate and eat as soon as possible after surgery to expedite the return of bowel function.

“We did a root cause analysis on almost every patient who got readmitted or had complications,” Dr. Haber says. “We audited all the cystectomies we’ve performed and looked at opportunities for improvement.”

The ERAP program is not the only way the institute is improving bladder cancer management. Staff members are also studying the biology of the disease and testing new drugs, under the purview of urologist Byron Lee, MD, PhD.

Dr. Lee recently received a Kimmel Scholar Award from the Sidney Kimmel Foundation for Cancer Research and a Young Investigator Award from the Bladder Cancer Advocacy Network. His current research involves how chromatin-modifier gene mutations contribute to bladder cancer development, progression and response to therapy.

Utilizing CRISPR

“These mutations occur in about 70 percent of bladder cancers,” Dr. Lee says, “so we think it’s incredibly important to understand what they do.” Dr. Lee uses CRISPR technology to mutate specific chromatin modifiers then analyzes the effect on the cell’s behavior. He has also bred a strain of mice with chromatin modifiers mutated in their bladder tissue.

The team participates in clinical trials of new therapies, including the latest immunotherapies. Cleveland Clinic investigators were involved in both the IMvigor 210 trial, which found that the checkpoint inhibitor atezolizumab is promising for locally advanced or metastatic urothelial cancer, and KEYNOTE 052, which found a significant response rate when the checkpoint inhibitor pembrolizumab was used as first-line therapy in cisplatin-ineligible patients with metastatic bladder cancer.

Cystectomies entirely robotic

Meanwhile, Dr. Haber and his colleagues have improved how they perform cystectomies. Rather than beginning with a robotic approach and switching to open when necessary, cystectomies are now performed entirely robotically, minimizing trauma and speeding recovery.

“We are adding to our already strong foundation,” Dr. Haber concludes, “through enhanced recovery, through a less invasive surgical approach, by focusing on basic research and by evaluating new drugs.”