Good news for patients with bladder cancer: “Breakthroughs in drug development and in our understanding of cancer biology have allowed us to safely preserve more bladders and to de-escalate care,” says Max Kates, M.D., the R. Christian B. Evensen Professor in Urology and Director of the Bladder Cancer Program.

This “slow and steady de-escalation” is happening in the care of both muscle-invasive and non-muscle-invasive bladder cancer (MIBC and NMIBC), Kates adds. “Our hope is that our therapies will prevent the cancer from progressing and prevent the need for a cystectomy (bladder removal). But at the very least, we are often able to preserve bladders, sometimes for years.”

Bladder cancer treatment has achieved synergy: powerful new drugs are showing such remarkable results that patients who weren’t considered candidates for surgery now have cancer that is now considered operable. “It’s been amazing,” says Kates. “Probably the most important development that’s occurred in the last half-century happened this past year with the approval of a combination of drugs called EV Pembrolizumab (EVP) for metastatic bladder cancer.”

When the results of clinical trials for EVP were presented at a national meeting of medical oncologists, the drug “got a standing ovation – which has never happened!” Kates notes.

Before this drug, patients diagnosed with metastatic bladder cancer typically saw a medical oncologist. “Now we are seeing such profound responses from this disease that we’re doing surgery to help consolidate some of these amazing responses from the systemic therapy.” It used to be that bladder cancer was not a multidisciplinary field, he adds. “Now that systemic therapies have improved, medical oncologists are involved at the early stages, and surgeons are treating disease they never used to treat.

That shows you how the field is completely changing in terms of how we’re thinking about it. We are seeing complete responses!”

Kates and medical oncologist Noah Hahn, M.D., recently started a multidisciplinary clinic for NMIBC at Johns Hopkins. “Together, we see some of the most complicated cases of NMIBC in the region, and we develop a tailored treatment plan for each patient.”

Doctors have known since the late 1970s that bladder cancer is “incredibly sensitive” to immunotherapy, Kates continues: “BCG is one of the oldest cancer drugs in the world, and one of the earliest forms of immunotherapy.” EVP is next-generation immunotherapy.

The Johns Hopkins Greenberg Bladder Cancer Institute is one of the few centers devoted to research and treatment of bladder cancer in the world. “We see more than 50 new bladder cancer patients a month,” says Kates, “and we have made an effort to have a clinical trial available to every patient in every disease space within bladder cancer – from the earliest stages to late-stage metastatic disease.” Many of those trials involve combinations of therapy: immunotherapy and antibody-drug conjugates, as well as traditional chemotherapy and targeted therapy.

Some of these are “unique options that we may be the only center in the country able to provide” notes Kates. This is what Kates wants patients and their families to know: “It does not need to feel like the end of your life if you receive a diagnosis of bladder cancer. The reason to come to a major center of excellence like Johns Hopkins is because we meld the art and science of medicine. The science is these new breakthroughs and the clinical trials. But at the end of the day, medicine is individual, and customizing the science to each patient, and their needs, and their family’s needs, is what makes a difference.”

Big Plans for The Future

Ron Singer and Penny Miller are partners, both inspiring examples of resilience, courage, and the power of a positive outlook. Ron was diagnosed with bladder cancer in 2018, the year his wife passed away after a long battle with pancreatic cancer. Penny lost her first husband after 38 years of marriage; he died of stomach and esophageal cancer. She married again, and her second husband died of a heart attack 14 years into their marriage.

In 2020, Ron and Penny found each other. They have big plans for the future, starting with a cruise in a few weeks. “There’s a lot more to do in life,” says Ron. “Both of my parents lived to very old age. Penny’s mom died at 99, and her dad was 101. God willing, we have a couple of decades left!”

Ron’s bladder cancer was diagnosed early, when traces of blood showed up in his urine at a routine physical. “I practically lived at Johns Hopkins between 2015 and 2018, when my wife passed away,” he says. He began seeing urologist Max Kates, M.D., and medical oncologist Noah Hahn, M.D. “They took care of me,” he says. “We decided at that time to do a bladder preservation scenario, which involved radiation, chemotherapy, and some other treatments.” The treatment was effective and allowed Ron to keep his bladder for six more years.

Ron has committed $100,000 over the next five years to support the newly established Non-Muscle- Invasive Bladder Cancer Multidisciplinary Clinic (NMIBC MDC) at Johns Hopkins – the first of its kind in the country – which Kates and Hahn co-direct. “We’ve been donating towards their research for years,” he says, “but we thought it would be a good idea to put those donations towards this MDC, and we will continue to support that clinic as long as they need it, so we can help other patients who are going through this.”

Over the years, even before the MDC was stablished, “I have basically been in a multi- disciplinary clinic – because every time I came to Hopkins, Drs. Kates and Hahn took care of me together. The two of them are terrific physicians. It was worth flying up from Florida and staying the two to three days each time.” Ron also has a local urologist in Florida who coordinates with Kates and Hahn.

Ron’s strong family support – his two sons meet him at the hospital whenever he comes to Hopkins, and Penny has accompanied him on every visit over the last four years – encourages him, and the care provided by Kates and Hahn bolsters Penny, too. “I have been so impressed,” she says, “with how wonderful, compassionate, supportive, and capable they are.”