Charles Ryan: Hello. I’m joined today by Professor Morgan Roupret who is a Professor of Urology at the Sorborne University and works at the Pitie Hospital in Paris. Thank you for joining us.

Morgan Roupret: Thank you.

Charles Ryan: I want to transition now, and I wanted to ask you a little bit about the increase in bladder cancer in younger individuals, and in particular younger women. And I hear that there’s an increase in the number of women undergoing surgery for bladder cancer, and what do you think is behind that?

Morgan Roupret: There is indeed a phenomenon, which has been depicted by certain experts about the fact that there is a rise of cases in younger patients with bladder cancer. It affects men and women, but I want to mention that in the guidelines, the median age, when you look at the epidemiology and the diagnosis is, 65, 70 years old. And, all of a sudden we have seen in our centers of expertise, many, many patients, maybe there was a bias because we recruit some patients that are referred to us. It’s a phenomenon that we have seen, and if it’s not a just a single case isolated, it’s a phenomenon that we felt needed to have a discussion around.

This is a reason why there was a special session at EAU congress about this particularity. What would be the reason there is not something that we have noticed in terms of tobacco consumption, occupational exposure, I would say as a so-called traditional oncological factor. We do believe that there is still a lack of knowledge according to the polymorphism. By that I mean individual genetic profile that are likely to interact with the environmental factor, and maybe initiate even more easily the bladder cancer phenomenon. But the point is that it is something that is true. And when you raise the problem of bladder cancer, especially in young patients, you raise also, and not being a woman, because in men you will remove the prostate. So there is no way that you can preserve the fertility.

In women, the tradition when you are facing a muscle-invasive bladder cancer is to remove the bladder, but not only the bladder, the uterus, and anterior part of the vagina. So, the discussion went into the possibility to have organ-preserving surgery. By that I mean, to focus only on the bladder to keep as much as possible the possibility for the woman to be pregnant. And also, the question of delivering a baby with a urinary diversion. So, we go back with the neobladder question and to the neobladder question, sorry. And that’s very important to keep that in mind.

So, the discussion was much more once again about the ability to being diagnosed with such a severe disease, but to be also in a position to maintain the woman fertility. And obviously it seems feasible, but once again there is maybe a risk that you take regarding the evolution of bladder cancer because you are not going into the gold standard, the ablation, extensive ablation of the organs. But if you explain properly the situation to certain patients, it’s just muscle-invasive, and not advanced disease with nodes, then maybe it’s a feasibility.

There is another point that we need to bear in mind, is that many of these patients receive also chemotherapy. And chemotherapy can affect also the fertility. So, it’s important to discuss with the oncologist, with the possibility to adapt the treatment according to this specific operative. And with the advent of the new checkpoints inhibitor, PD-L1, PD-1 drugs, the question of the impact, not only on the cancer, but on I would say as a side effect of the new drugs on the fertility of the patient, it’s also maybe something that we need to consider because these new drugs are not only very promising on the oncologic perspective, but also on our ability to decrease the side effect because for many, many years, so we use chemotherapy cisplatin-based chemotherapy. It is efficient but is very toxic for the patient.

Charles Ryan: Yeah. Yeah. Good, really interesting perspective. I had no idea actually that there is a rise in increased… a rise in the incidence of bladder cancer in young women, and obviously a whole new host of other clinical issues that you have to confront.

I want to thank you for talking to me about this today. It was a very enjoyable conversation.

Morgan Roupret: Thank you.

Charles Ryan: To the editor, I want to go back and ask one more question because you touched on checkpoint inhibitors, so I wanted to ask another question. With regards to the choice of urinary diversion, does neoadjuvant chemotherapy or neoadjuvant immunotherapy affect those outcomes at all or that quality of life?

Morgan Roupret: In fact, there was a question about the fact that a patient who received a systemic treatment before radical surgery could have more difficult surgery for the dissection of the tissue. So, to be very honest, we are at the time of beginning our experience with immunotherapy. But for chemotherapy, it’s quite clear in the literature that there is no increase of perioperative morbidity. And, you should usually start the surgery between two and three months after the end of chemotherapy. So, you can have a little bit of time for the tissue to be ready for surgery. And, everyone is saying that there is no way that the systemic treatment should influence the choice of the urinary diversion. And there is no reason why I should think otherwise for the immunotherapy.

Charles Ryan: Yeah. Just important to make that comparison or that comment. And we’ll see what happens over time I guess with immunotherapy, but I’d imagine, there’s probably no increased risk.

Morgan Roupret: Yes.