MedEvidence! Truth Behind the Data

From Probing Prostates to Bladder Breakthroughs

• Dr. Michael Koren, Dr. Yaw Nyame • Episode 349

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Urologist Dr. Yaw Nyame joins Dr. Michael Koren to discuss bladder and prostate cancers. Dr. Nyame talks about his journey through college - including the choice between rock stardom and medical school - and how he got to the Fred Hutch Cancer Center in Seattle. Dr. Nyame explains symptoms, the history, and treatments for prostate and bladder cancer. He tells us "if you have blood in the urine, you definitely want to get to your primary care doctor." He also expands on gaps in cancer outcomes for Black men. Along the way, we weigh benefits and harms of PSA screening and talk honestly about sexual health after treatment.

Show Note: Lynch syndrome is a genetic condition also known as hereditary nonpolyposis colorectal cancer (HNPCC). It represents an increased risk of several cancers, including colorectal, endometrial, gastric, ovarian, and pancreatic cancer. It is caused by an error in the DNA mismatch repair mechanism, which normally corrects for random insertions into the DNA code.

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Announcer:

Welcome to MedEvidence!, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren:

Hello, I'm Dr. Michael Koren, the executive editor of MedEvidence! And I'm really excited to introduce you to a new friend named Dr. Yaw Nyame, who's a nationally prominent urologist, very passionate about research, particularly in black men, and is going to educate us today about bladder cancer. So, Yaw, thank you for joining us here in MedEvidence!

Dr. Yaw Nyame:

Yeah, the pleasure is all mine. Thank you for having me.

Dr. Michael Koren:

So let's just start by introducing you to the audience. Uh tell us a little bit how you ended up where you are, which is in Seattle right now, but tell us your whole progression. Um we do have a lot of doctors who listen in and they're fascinated by how different physicians got to where they are now. So just run us by your childhood and in a quick version of how you got to where you are now.

Dr. Yaw Nyame:

Yeah. Yeah, I was born in Athens, Georgia, when my dad was doing his PhD in biochemistry. Um, ironically, his research was all in the schistosome, which is a parasite that infects the bladder and actually causes bladder cancer. Maybe some like heavy foreshadowing there that uh feature in urology. But you know, I think I my dad is a biochemist. My mom was a school teacher who became a nurse when she when my parents emigrated to the US, and I was kind of inundated with academia and healthcare in my household. So-

Dr. Michael Koren:

Interesting.

Dr. Yaw Nyame:

Um I think they were the two of them were really big inspirations for me being interested in the sciences. Um, I went to college at Duke in North Carolina, that's probably the first time that I really had an inkling that um being at the forefront of academic medicine would be of interest to me, just and some of the role models that I identified along the way. A lot of them were actually just basic scientists uh at the time because I was still fairly undecided. But yeah, I think the clinical setting and healthcare became uh very interesting to me. And after college, believe it or not, I was deciding between med school and being a rock star.

Dr. Michael Koren:

Really? Oh, what a coincidence. Same here.

Dr. Yaw Nyame:

Uh but it was uh after college, I moved to DC to kind of ponder which one of those two pathways to try and go down. And um, it was in DC that I really became interested in health advocacy, you know, the patient side of things, really meeting people at the time that were really championing new concepts like what you know, cancer survivor. You know, that was a term that was really being popularized and resources are being allocated to support cancer patients at that time. I don't think I realized how much each one of those little experiences would add up to me being in med school and subsequently uh in Chicago at Northwestern thinking, okay, I want to pursue cancer care, but that always kind of wove in and out of my, you know, my interests. And so um, you know, I find myself in, I found myself in Seattle honestly, because I really wanted to pursue research that was patient-centered, um, you know, health services research that put patients first and had conversations with patients. I've had a lot of life experiences that have led me to think that that's important, including um an MBA experience while I was in Chicago. But I think the consumer, you know, you know, the patient is the is the most important person uh in the whole algorithm.

Dr. Michael Koren:

Absolutely.

Dr. Yaw Nyame:

And oftentimes we don't find good ways to integrate them into the research and our discovery and our innovation. So that's really become important to me uh and the work I do.

Dr. Michael Koren:

I love that. I love that. So a few questions about your biography, fascinating biography. Do you have siblings and are they involved in healthcare? First question.

Dr. Yaw Nyame:

Yeah, I have a sister. She's 10 years younger than me, so we have a big gap. Uh-huh. Uh, she is actually a pharmacist at Johns Hopkins. So, yeah, very healthcare um family.

Dr. Michael Koren:

Yeah, it's interesting how that that happens. Um, you know, families tend to produce healthcare people. Uh, that's one thing. And then what instrument do you play? Are you a singer? Uh tell them tell me about your rock star career.

Dr. Yaw Nyame:

So I my pouring to music started with the trombone. I got obsessed with it because my band director uh came to our our fifth grade class and did this like car racing thing, you know, with the slide on the trombone. And actually, I took that quite far. I played in the orchestras, I played actually in the orchestra in college for a year, but then just kind of like didn't have the time. Um, but as I transitioned from high school where it was, you know, trombone and and jazz band, um, you know, symphonium, um, the symphony, excuse me, and the orchestra, uh, I transitioned away from that to guitar. Uh, and guitar became my my new love in college and actually made my closest friends in college, uh, three of whom are physicians, through a shared love of playing guitar in the dorm. And uh, and we started a band when I was in college that led to a really awesome college experience of playing shows around campus.

Dr. Michael Koren:

Uh very cool. Well, I play keyboards we'll have to jam together at some point.

Dr. Yaw Nyame:

We'll make that happen.

Dr. Michael Koren:

All right. So let's transition to what you do day to day. Just uh tell us how you spend your days at Fred Hutchinson uh center in Seattle.

Dr. Yaw Nyame:

Yeah, so here at the Fred Hutchinson Cancer Center uh in UW Medicine, I spend half my time being a scientist and half being a clinician. Uh sometimes that half of clinician feels like more than 50%. You know, where it's uh we're a very busy program, and I see I'm very undifferentiated. So there are some urologists that specialize in cancer that may see only prostate cancer patients or only bladder cancer patients. I manage patients with bladder, prostate, kidney, and testicular cancer in our in our cancer center and um and really enjoy that variety. It means meeting different people, uh, different age ranges, different walks of life, because all those cancers kind of have um different predispos predisposing factors and so present at different um um stages of of life. And and there are other risk factors too that might increase your risk. So it's um uh it's really rewarding for me. The other half of my time is doing research. I work specifically with black men with prostate cancer just because of how much of a public health crisis the disparity in prostate cancer has been among black people. And as I mentioned earlier, I think the best way to figure out how to solve that crisis is to directly involve patients so that we better understand what's happening in their lives uh and what opportunities may exist to close that disparity gap, which black men are twice as likely to die from prostate cancer compared to their peers. And that's been true for 50 plus years of collected data through the federal government.

Dr. Michael Koren:

Wow. Well, we'll get back to that, but I'm gonna do a little bit of a sort of uh a segue to something that we've gotten questions about. So one of the things we like to do here at MedEvidence! is hear what our listeners and viewers want to learn about. And we've had a couple of requests to have somebody break down bladder cancer for us, and it sounds like that's right up your alley as well. So maybe maybe you can help us a little bit by just explaining the incidence of bladder cancer, how it usually presents, and and what are the treatment options and what are the research questions right now?

Dr. Yaw Nyame:

Yeah. So bladder cancer is the tenth most common cancer in the United States. There's about 85,000 new cases estimated for 2025 that will be diagnosed.

Dr. Michael Koren:

In the US.

Dr. Yaw Nyame:

In the US, yeah. In the United States, and about 17,000 people who will unfortunately die from from bladder cancer in the in the US. Um, you know, it is a typically a cancer that we diagnose from symptom, you know. So I manage cancers that are found incidentally, meaning you go in for a CAT scan and oh, there's a spot on your kidney, and you come see me. Uh, I manage screened cancers like prostate, you get your PSA test from your primary care and it's elevated, and you get diagnosed. Bladder cancer is one of those symptoms um related diagnoses in that patients will present with blood in the urine. Um, it is most diagnosed in later decades of life, you know, and uh individuals in their 60s, 70s. Um and and and so most of the time if I'm meeting somebody that's had that diagnosis, it's because they had blood in the urine and they got a evaluation that's usually a CAT scan and a cystoscopy, where we look inside the bladder with a with a skinny camera um that leads to the to the discovery of those tumors that then get biopsy.

Dr. Michael Koren:

A breakdown between men and women for bladder cancer?

Dr. Yaw Nyame:

Yeah. Men are three to four times more likely to be diagnosed with bladder cancer in the United States. And that really has to do with what is the primary um risk factor for developing bladder cancer, which is tobacco use. And as we know, um in the US, you know, through um the military and other things, you know, there's there was a heavy smoking culture, much heavier than than present day, and men were more likely to smoke, and that is is is a big part of why we see more bladder cancer among men in the U.S. Interestingly, I was just in Ghana operating as part of a mission trip with a group called IVU Med. Um, and all of our patients were women. And uh, one of the individuals there was asking me what I thought. And I have a hypothesis, which is in Ghana, women cook over coal stoves that are really small in their households, and they're sitting near that and and inhaling that smoke. And I think so, again, it just goes to show that that burned material that's inhaled has a lot of carcinogens that get filtered out in the urine that might drive bladder cancer um development. There are other risk factors, some industrial chemicals that increase risk. So we used to talk about uh um dyes and and aromatic amines, you know, like taking you way back to your your chemistry days, but there are definitely some toxins that increase uh bladder cancer risk. We've been doing some work looking at arsenic here through one of my partners here at Fred Hutch and water supply. Um and then there's a strong genetic component. So for instance, Lynch syndrome, which I think many of us would think of as a colon cancer risk factor, increases your risk of developing cancers of the inner lining of the bladder called urethelial cancers, both of the kidneys and the bladder. And that inner lining is in in continuity. So you it's a very similar type of cancer that gets developed in both places.

Dr. Michael Koren:

Is Lynch named after a person or is that an acronym?

Dr. Yaw Nyame:

It is named after I a person, I believe, and and it's a uh missense mutation um that um I I that is not like I'm not a geneticist, so I don't want to speak too much of it.

Dr. Michael Koren:

We'll do we'll we'll do a show note on that to cover that.

Dr. Yaw Nyame:

But those are the that's pretty common in uh in some colon cancer patients.

Dr. Michael Koren:

So got it. So uh is the diagnosis of bladder cancer death sentence, or are there things that you can do uh kind of help us understand what the workup looks like for the average person that gets diagnosed?

Dr. Yaw Nyame:

So as I mentioned, uh it's diagnosed typically from blood in the urine. So, you know, if I have one message for everyone on that's listening, is if if that is a symptom that you develop, you know, that especially if you have blood in the urine without pain, but in any context, you definitely want to get to your primary care doctor and get a referral and to see a urologist. You know, the majority of the cancers we diagnose are early stage, meaning they're only on the most inner linings of the bladder and they have not penetrated into deeper layers. Um, and and and that carries a very different pathway, both in how we uh manage those cancers and what the prognosis is compared to um cancers that are more advanced. So the earlier it's discovered, the better. I think I mentioned earlier that the workup involves a CT scan, meaning we get um, you know, a scan of your abdomen and pelvis, usually with contrast, so that we can kind of get a really good understanding of the anatomy of the kidneys and bladder. Uh, and then a cystoscopy where we take it and a camera that's a little about the size of a small catheter that we pass into the bladder to evaluate the bladder. If we see one of these tumors in the bladder, then we take you for uh a surgical procedure where we use uh electricity to shave a little piece of your bladder uh and the tumor and we send that to a pathologist for the for an evaluation.

Dr. Michael Koren:

Very cool. Um how how often can you deal with with bladder cancers just with local means versus major major surgery?

Dr. Yaw Nyame:

So I always say there are two things we want to know when we do that bladder biopsy when we're evaluating a bladder cancer. The first is how aggressive is a bladder cancer? So we have some cancers that are low grade, meaning overall, when you look at the architecture of the cancer under the microscope, it's not too chaotic. Um, sometimes I joke, you know, if it's a brick wall, you've got bricks that might be slightly different sizes, mortar in between the bricks that's not consistent, but at least it looks like a brick wall. Then you have high-grade tumors that might look like, you know, uh, my six-year-old built the wall, made the bricks, and laid it himself, right? Really disorganized. Um and so those two different um settings give different options. And then the second one is how advanced is a cancer, right? Is it only in the inner lining or is it in the muscle of the bladder? And the muscle wall of the bladder really is that uh line in the sand where we go from treatments inside the bladder typically is a first line, to if it's involving the muscle in the bladder, typically uh chemotherapy, followed by radical treatment, which is in the US typically bladder removal, although radiation can also be considered in patients uh who may prefer to keep their bladder or may not be healthy enough for bladder removal.

Dr. Michael Koren:

Got it. Uh what's the role for infusing a chemotherapeutic agent in the bladder versus systemic treatment?

Dr. Yaw Nyame:

So if it's um one of those uh non-muscle invasive cancers, that's a term we use. If it's only in the inner lining of the bladder, then we really do have two um predominant uh therapies that we put inside the bladder. The first one is actually an immunotherapy, and it's an old immunotherapy. It's BCG, which was a TB vaccine, and we administer that inside the bladder, and that has a pretty good success rate for treatment, um, somewhere around 70%, is what I quote, uh, over a two to three year span. Um and then the second therapy, which is really coming into um the foreground, and we just completed a clinical trial um that is gonna hopefully read out uh within a year or so, uh, that that will hopefully show us a chemotherapy combination of gemcitabine and docetaxel are is as just as efficient as the BCG. The problem with the BCG for us is drug shortages. I mean, it really has made managing and treating this non-invasive bladder cancer very challenging because of just not having the drug available. Um, but those are have been our two primary inside the bladder treatments. We are have had a very big revolution in this management of non-invasive cancer, and there are a lot of new drugs that are coming on the market. This is in part because I told you the efficacy of treatment is around 70% at first time. Some may say it's lower, maybe closer to 40 or 50%. So one of the nuisance things about bladder cancers is that they want to do two things if they're high grade, especially. If they're low grade, they are do the nuisance thing of coming back. So recurrence. And we see that with high grade too. But high grade cancers not only want to recur or come back, but they want to progress or move to deeper stages of the bladder wall or spread beyond the bladder. And so that is really um the thing that we're fighting in uh when we're giving therapy is trying to um make sure that we're keeping a close eye on the bladder for those recurrences. And we also don't want to wait too long or give treatments that are not working, um, in the in the case that a cancer may progress, which you know, once the bladder cancers have spread beyond the bladder, you know, they typically are incurable. And that can affect quality of life. And uh um uh well, obviously that affects, let me start over. Once they move beyond the bladder, they're often incurable. And many of the treatments that we have to offer can have significant quality of life impact. So that that is the reason why we we're looking to be more aggressive, especially in the setting where these cancers that are still non-muscle invasive come back.

Dr. Michael Koren:

Are there any biomarkers for bladder cancer similar to PSA for prostate?

Dr. Yaw Nyame:

There are not, there's not a biomarker like PSA, but there's definitely new products that are coming onto the market that are looking at uh shed cancer DNA or shed cancer cell uh cells uh in the urine. And so there are some products that are starting to become commercially available, but none of them have moved into the space of where I would say at prime time usage.

Dr. Michael Koren:

Got it. And how about people that have a family history of bladder cancer? Are there circumstances where people may not have any signs or symptoms, but should still be screened for bladder cancer because of a high genetic risk or exposure risk?

Dr. Yaw Nyame:

We do um some screening, especially in patients who have Lynch syndrome. So I brought that up earlier, uh, where we get pictures to make sure there is no evidence of tumors within the kidney, especially. Um, and we may offer some scopes, um, but there isn't routine screening that's recommended just simply for having a strong family history. It's mostly in those patients who have rare genetic variants um uh in their DNA that that pushes us to think about uh screening for multiple cancers, and in that case, bladder and what we call upper tract urethelial cancer may be included in that.

Dr. Michael Koren:

Fascinating. Well, that was a true master class. Thank you so much for educating me and our listeners and and viewers. So let's transition to your passion, which is this discrepancy in incidents and outcomes in prostate cancer compared comparing black men with other populations. So I'm fascinated to learn about what you're doing, what you're studying now and what you're trying to think through to mitigate this discrepancy.

Dr. Yaw Nyame:

Yeah. Uh well thank you for first of all for giving me the opportunity to talk about bladder cancer. I know because so much of my work is in prostate cancer, um, that sometimes uh people are not aware of my passion for supporting bladder cancer patients um as well. And um, and and certainly there's a lot of exciting research that I'm fortunate to be able to contribute to through my partners who have um, you know, research programs in that space. You know, as I mentioned earlier, what what we have done over the last five years is just create a forum for black prostate cancer um survivors um to contribute to the advancement of prostate cancer research. And we've through done that through an organization that we call BACPAC, which stands for the Black and African Descent Collaborative for Prostate Cancer Action. I did not come up with that name. Um, but at BACPAC has been a really great group. We started with two individuals in 2020. You know, we have now well over 40 uh people that serve in advisory roles that are either survivors or stakeholders, such as researchers, that help support the work we do. Um, and we've really spent the last five years asking the question what research questions are most important? What approaches will be successful in ensuring that um people from socially marginalized populations can participate because there are some hurdles there. Um and uh and and what strategies are uh are needed um to make sure that we answer those important research questions appropriately. Um and so we've been really lucky to have funding from the uh multiple um sources, including National Cancer Institute, Department of Defense, PCORI, um, to help do this work. And right now, all of our energy and focus is on doing um what would be the first screening trial uh in in black uh men to understand how we can maximize the benefit of a PSA-based screening protocol while mitigating harms, right? Because that is that is a challenge that we have in prostate cancer screening, is that although we can reduce death from prostate cancer with PSA testing, we often do so at the um at the cost of introducing harm and unnecessary biopsies and anxiety around whether one may have prostate cancer for a test that um has a lot of false positives. Um and in detecting cancers that men would would probably be better off not having been diagnosed with because they're more likely to die with that type of cancer than from that type of cancer. I actually believe quite strongly that when you have a high-risk population, you have actually even a higher risk of detecting some of these low-risk cancers uh and doing more harm. So, yes, we need to be thoughtful in screening high-risk populations and um so that we can reduce the burden of disease, but we also need to do that in a way where we don't also uh maximize harm.

Dr. Michael Koren:

Interesting. Uh, are you also involved in interventional clinical trials in prostate cancer?

Dr. Yaw Nyame:

At this time, no. You know, I am a um prostatectomist, so I do a lot of prostate cancer treatment in the localized setting. Uh as a program, you know, I help collaborate with investigators that are thinking about some interventional um uh components of the care we deliver. So, what does that look like? Well, are there some drugs that we can give around the time of prostate removal that might reduce the chance that cancers come back? But you know, one of the um one of the realities of prostate cancer is that it's the the simple treatments that we have now, removal and radiation, are really effective, even in high-risk settings. And it seems like adding additional therapies don't doesn't always give us additional benefit. Um, and so that kind of limits the amount of investigation we can do. A lot of our efforts in prostate cancer research are focused on uh the diagnostics and and the and um that includes the screening component, but we you know, can we find cancers, small amounts of cancers that might be outside of the prostate, you know, that might impact what kind of treatment approach we we take or how we manage cancers after treatment if PSAs come back, you know, in that recurrent setting. That is very different from bladder cancer, just to transition a little bit, um, where a lot of the exciting investigation is in new therapies that are coming on board. You know, two years ago, if you asked me about bladder cancer, I would have said, well, there's one chemo combination, um, and it, you know, it doesn't really have a strong complete response rate, and um, but it's it's what we know to be most effective. Now we have an antibody drug conjugate that we pair with an immunotherapy that's really revolutionized um bladder cancer treatment, especially in the advanced stage, that has, you know, a uh um a notable complete response rate. So um it's just uh very two different cancers uh in two very different um phases.

Dr. Michael Koren:

Interesting. Uh one thing that I've read about uh on on prostate cancer treatment, and I'm sure it's applicable for bladder cancer, is concerns about losing sexual function during the treatment. Um you maybe want to comment on that.

Dr. Yaw Nyame:

Yeah, I mean, that's a big part of what we're learning in having conversations with patients and community members about what may be impacting their decision to screen or not screen, right? Um and the fear and and which are real and concerns about impact on sexual health and and urinary health, to you know, uh, I would argue just pelvic health in general. So, yeah, very similar risks for erectile dysfunction with with treatments. But one of the things that I always sort of pause and and and highlight is that erectile dysfunction is actually quite common in men uh at the ages in which we are treating them for prostate cancer. So if you take a non-prostate cancer cohort and look at what the rates of some degree of erectile dysfunction is, starting as um young as in the ages of 40 and beyond, there are large, larger than report, you know, I think um talked about populations of men who are experiencing some degree of ED, uh, and that rate can be as high as 70 or 80% of patients who are queried. And that's not to say that they have no function, but they have definitely diminished function. And so that is one of the things that really complicates um erectile recovery after localized treatment. I quote a 50% rate of erectile dysfunction for surgery if a nerve-sparing procedure is done. That's similar to radiation, although the timelines are really different. So with surgery, obviously erectile dysfunction happens right away, whereas with radiation, you have decline over time. So something that we counsel men on. There are a lot of great resources, just like there are for the general population to support uh erectile health, if that is a strong priority for a man, um, that that's um uh that that we can you know operationalize for for patients. And so one of the things that I think is really important and I have learned is not to say, well, there's a high degree of erectile dysfunction with this treatment and walk away from the conversation, but to really highlight that erectile dysfunction is common. Certainly these treatments are not going to make um have the potential to um accelerate decline, uh, but that there are a lot of really effective therapies that exist. And and you know, for instance, for us in our practice, I have wonderful partners that can um that support my my patients in erectile um health post-treatment. Uh, and and those types of urologists exist across the country and institutions um like ours and even in in community settings.

Dr. Michael Koren:

Well, Yaw, this has been an absolutely fascinating and educational experience for me and hopefully for our viewers and listeners. Uh any last words of wisdom or any important take-home points you wanted to make before we uh we sign off?

Dr. Yaw Nyame:

Yeah. Well, I think even though a big focus of today was bladder cancer, you know, I urge healthier, younger men to at least start engaging in the conversation of about PSA-based screening with their primary care doctors. And that that's what it's supposed to be, right? You have a conversation, understand what the benefits and harms of a PSA test would be for you. Uh, and and I think part of that conversation, understanding what your risks may be, you know, is it run in the family? Do people who look like you have higher risk of being diagnosed or dying from prostate cancer? Because those things are really important. On the bladder cancer front, if you have blood in your urine, that's an emergency. Definitely seek medical um care in that setting. And for those who have been diagnosed and are trying to understand how to work their way through this really challenging diagnosis, know that there are a lot of great organizations that exist to support patients. Uh, you know, I would be remiss if I didn't shout out the bladder cancer advocacy network, BCAN, um, that has a lot of great resources to support patients and has a large patient community uh where you could find someone who's been in your shoes to talk to, to kind of see. Guidance.

Dr. Michael Koren:

Well, Yaw, thanks for the great information, and thank you sincerely for joining us here at MedEvidence!

Dr. Yaw Nyame:

My pleasure. Thank you for having me.

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