Talking Hope: Urologic cancer: Keys to prevention, early detection and treatment

3 of the 6 most common cancers in U.S. men are urologic cancers.

Urologic cancers rank among the most frequently occurring cancers in the United States. Some can develop in both men and women, while others are specific to men. In this episode, renowned urologic researcher and clinician Cory Hugen, M.D., shares what to know about urologic cancer, how to reduce risk, and advances in early detection and treatment that are bringing new hope to patients. Dr. Hugen practices at City of Hope Orange County Lennar Foundation Cancer Center, where he specializes in caring for patients with urologic cancers such as prostate cancer, bladder cancer, kidney cancer, testicular cancer and penile cancer. He has been the lead or co-investigator on dozens of clinical trials in addition to being a multi-decorated physician serving in the United States Air Force.

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Darrin Godin: Hello and welcome to Talking Hope. I'm Darrin Godin and I'm pleased to be speaking with Urologist, Dr. Cory Hugen. Dr. Hugen is a renowned urologic researcher and clinician who practices at City of Hope, Orange County, Lennar Foundation Cancer Center. He specializes in caring for patients with urologic cancers such as prostate, bladder, kidney, testicular, and penile. Dr. Hugen has been the lead or co-investigator on dozens of clinical trials in addition to being a multi-decorated physician serving in the United States Air Force. Dr. Hugen, thank you for your service and thank you for joining us on the podcast today.

Dr. Hugen: Thank you for having me. Really happy to be here and speak today about urologic cancers for City of Hope.

Darrin Godin: Thank you. Well, we know some cancers of the urinary tract can occur in both men and women, such as bladder and kidney cancers. Others are more specific to men, prostate, and testicular, but urologic cancers are not uncommon. In 2024, an estimated 83,000 adults will be treated or rather diagnosed with bladder cancer, and prostate cancer is the second most common cancer in men, for example. So it's important for all of us to know about urological cancers so they can be caught early and treated. So Dr. Hugen, what are urologic cancers and why do they develop?

Dr. Hugen: Well, urologic cancers are, essentially, any form of cancer that starts in the urologic tract or in a genital urinary organ. For men, urologists treat testicular cancer, in women, ovarian and uterine cancer are treated by our gynecologic oncology colleagues, but essentially, anywhere where urine is either produced or travels through, as well as the testicles are cancers that urologic oncologist would help manage and treat.

Darrin Godin: Thank you. What are some of the risk factors?

Dr. Hugen: Well, surprisingly to most people, the biggest risk factor for most urologic cancers is actually smoking. People are often surprised when we tell them that, but for both bladder and kidney cancers, the biggest risk factor that we know of is smoking. There are other risk factors that you can be exposed to, occupational exposures, which are fortunately becoming more and more limited as workplace safety increases, basically, where you grow up, sometimes the water has a chemical in it that has been known to be associated with urologic cancers. Again, fortunately, that is decreasing. But there are a lot of cancers that develop that you can't do anything about. You're either born with that genetic abnormality, or just from a fact of living long enough, a genetic abnormality occurs to you that, unfortunately, doesn't get corrected by your body, and so there's risk factors that you are exposed to or you do to yourself, but there's also a lot of risk factors that you can't do anything about that you're either born with or that happens to you.

Darrin Godin: Are there certain ages at which people start to see more urologic cancers? Is it a misconception that it's only older adults?

Dr. Hugen: Well, it is true that the majority of urologic cancers occur as we age. So age is certainly a risk factor for the majority of cancers. Testicular cancer is the abnormality within that group where it happens to occur mostly in younger men and boys, starting around age 15 to 30, 35 is the prime age for testicular cancers. But the other cancers, age would definitely be a risk factor. Surprisingly though, we're seeing more and more cancers, and not just in the urologic field, but in all fields. There seems to be an age creep going down as cancers being occurring more and more in younger people. We're finding these, unfortunately, cancers in people as young in their 20s and 30s where we weren't seeing that before, but we are now seeing that more frequently today.

Darrin Godin: I know you don't have a crystal ball but why do you think that is? That's interesting you bring that up. I mean, the American Cancer Society just released some numbers recently that are startling and showing that a lot of cancers are starting to see a younger age of onset. So as a physician being in this field of oncology, any thoughts on why that might be?

Dr. Hugen: I wish I had the answer. I think there are certain risks that jump to mind. I think obesity is a thing that is occurring more and more commonly in our society, in our community. Obesity is a risk factor for cancers. It's been shown multiple times. The exact etiology is somewhat unknown, but there's a clear association between obesity and cancer. I would be shocked if our diet and how we consume foods and drinks. A big report came out, actually, last week about all the nanoparticles and nanoplastics that we consume from drinking all our bottled water and beverages, the amount of concentrated sugars we take in. I'm sure all these factors that are playing a role. I don't think we'll be able to pinpoint a particular etiology for this but it's certainly concerning.

Darrin Godin: So what steps can a person take to reduce their risk? And you've been talking about some of those risks and things that people can and can't do, but are there screenings that we can do to really capture some of this early?

Dr. Hugen: Yeah. Screening doesn't reduce your risk, screening will help detect. So to reduce risk, we're talking about lifestyle modifications, we're talking about exercise and diet. A lot of the things, we assume are common sense, that we know we should probably do but they're not always that enjoyable to eat that vegetable instead of that piece of cake or whatever it might be. For urologic cancers and probably, all cancers, in particular smoking is still a huge risk factor. Fortunately, less smoking occurs now than 20, 30 years ago but unfortunately, a lot of that risk doesn't go away after 20 or 30 years and you unfortunately reap the consequences of decisions made earlier in life as you get older. So as a young person trying to prevent cancers, a healthier lifestyle, diet, exercise. And then as far as screenings go, those help detect cancers at earlier stages and earlier risk factor or how aggressive those cancers might be or how far advanced they may be. In all cancers, that doesn't always lead to a better outcome but for the majority, it does.

So we talk about screening, for example, screening colonoscopies for colon cancer. In prostate cancer, we talk about prostate cancer screening with PSA testing. That's a controversial field with PSA screening, you want to talk to your doctor about that and how that might fit into your personal journey for breast cancer. There's all these screening tests that can be done, and it's just regular checkup with your physician. One thing for urologic cancers, particularly, as you mentioned earlier, a lot of these occur much more in men than in women, is this denial or this kind of... ignoring the symptoms. So for example, it's not uncommon for me to see a patient who comes in and says, a year ago, I had blood in my urine. It went away, so I thought everything was okay. It happened a few weeks later, never happened again, and then six months later, it happens.

And for that six months, it was this... not doing anything, not being proactive about it. So if you have those kind of symptoms, blood in the urine is a big thing for urologic cancers. We also see this in women. Women will come in and have been told that they had a urinary tract infection over and over and over and treated with a year's worth of antibiotics. Finally, they come in and get evaluated and unfortunately, sometimes we'll find a cancer. Not always, and thankfully, but it is certain, don't ignore those symptoms because a lot of those signs and symptoms aren't there for urologic cancers.

Darrin Godin: So you speak of blood in the urine, but are there other specific symptoms that people should pay attention to?

Dr. Hugen: Well, blood in the urine is by far the most common, painless blood in the urine, where you sit down and you look at the toilet and you're like, oh my goodness, there was blood there. It didn't hurt when I urinated. A lot of the other symptoms that we talk about are oftentimes associated more advanced cancers, if you actually feel a mass for kidney cancer, for example, or if you're experiencing a lot of pain in the back or the side, that can be associated with more of an advanced kidney cancer. The majority of... I shouldn't say the majority, but a lot of the tumors that were identified are actually incidentally detected. A CT scan was done for a workup of a different disease, or someone got a fender bender and they went to the ER and got a CT scan and they noticed a two or three-centimeter mass on the kidney or things like that. We're finding a lot more of these tumors at earlier stages, not because we're necessarily screening for them, but we're incidentally detecting them for workup of other problems.

Darrin Godin: So let's shift to how these sort of cancers are treated, and are there any advances that you're seeing in treatment that are really making the most difference for patients?

Dr. Hugen: There are. Each cancer can be treated quite differently. In men, for example, three of the top six cancers are urologic malignancies. In women, that's not quite the same numbers but still, a lot of women have cancer. So whether we're talking about treating kidney cancer or bladder cancer, adrenal cancers, penile cancers, or testicular cancers, they're all treated very differently. One thing that is true or universal to the majority of these cancers is that surgery still plays quite the mainstay or probably, the primary treatment modality, at least partially. We're seeing advances in some of the medications, for example, non-muscle invasive bladder cancer, and muscle-invasive bladder cancer for 30 years, really no advances, and in the last few years, somewhat of an explosion of different options that we can use, putting medications within the bladder using non-chemotherapeutic options for more advanced cancers.

Kidney cancer would be the same way while surgery is still almost the mainstay for local kidney cancers, we're freezing tumors more, we're using stereotactic radiation therapeutic options for kidney cancers, and then the whole role of immunotherapy has really exploded in the field of kidney cancer. So we're excited for these new options. Obviously, we don't want morbidity and treatments that lead patients with long recovery periods and leaving them worse off than when they started. So we're excited about these more non-invasive and immunotherapeutic options that are available for a lot of the urologic cancers out there.

Darrin Godin: That sounds promising. When a patient is first diagnosed with a urologic cancer, what are the benefits of seeking care and treatment at an NCI-designated comprehensive cancer center like City of Hope?

Dr. Hugen: I think the benefits, particularly, at City of Hope where we are a cancer hospital and a cancer clinic, this is what we do day in and day out. There are certainly roles for treatment centers that are not cancer-focused. There are, obviously, a lot of diseases out there that aren't related to cancer, but the primary benefit for coming to a cancer center is the expertise that you're going to see, you're going to see a physician who really only treats that particular illness or disease or a small range of diseases that are associated with what you're coming in for. The other big advantage for coming to an NCI-designated center is the built-in quality that you can expect. We're continually vetted by regulatory agencies to make sure that we meet the standard, and then the option and exposure to clinical trials and advancements in treatment. There's a reason why there's standard of care for treatment. These are developed at centers like City of Hope, and we keep pushing the boundaries of the next new treatments and exposing and giving patients options to get those next-generation treatments, hopefully, resulting in the best outcomes possible.

Darrin Godin: Great. Throughout my career in healthcare and experience with my own health or the health of my loved ones, I've learned that we need to be our best advocates for ourselves. How do you suggest patients advocate for themselves to get access to the best care when they're facing a cancer diagnosis? Should they just tell their doctor, I'd like to get a second opinion, or I'd like to get treatment at a cancer center? How do they advocate for themselves or how does a loved one advocate for their family member?

Dr. Hugen: I think you nailed it, is you've got to be your best advocate, you've got to be the squeaky wheel of asking for that second opinion. Insurance companies are striving for efficiency, and your goals and their goals probably don't align. So being an advocate for yourself, getting... and I encourage my own patients when they come here, get a second opinion. What I'm suggesting may not be in line with what you're thinking or what your goals are. So even within our own institution, we get second opinions. So I think being your own advocate, having a family member, we know that patients with strong social support do better than patients who don't, and part of that is having a family member or a loved one help advocate for you. And if you don't have that, we have that here at City of Hope. We have patient advocates, we have nursing navigators who are out there working on your behalf to get you into the right places at the right time to get your treatment.

Darrin Godin: Thank you for that. I appreciate that. So tell us a little bit about your experience being a physician in the military, and how long did you serve?

Dr. Hugen: So the military branches have an opportunity not just within urology but basically, all specialties, where the military branches have their own active duty military physicians and nurses and hospitals and clinics in an exchange for a tuition reimbursement during medical school, in my case, for example, you agreed to work for the military for a period of time when you're done with your training. So after I finished my residency, I was an active duty Air Force urologist for four years. I was stationed in San Antonio and actually spent the most of my time as an active duty physician at a VA hospital, a veterans hospital in San Antonio. Just because of the military community there, there's a lot of active duty physicians, not only in the military hospitals there, but also in the VA hospital there. So during that time, I was ... veterans tend to be older, and like we talked about, age or risk for urologic cancers, and at that point, I was a general urologist treating everything that came in through the door and seeing more and more of the advanced cancers that occur in veterans.

A lot of exposures occur to veterans who were deployed years ago, particularly, in Vietnam. That era is coming through the VA. It triggered or reinstilled my desire to do urologic oncology. So after my time in the military, I went back to fellowship to do a urologic oncology fellowship. So, military medicine is a little bit different focus than civilian medicine. I did have the opportunity to serve overseas in a little bit different capacity than my day-to-day basis in the United States, but overall, very fulfilling time in my life for those four years.

Darrin Godin: Well, thank you for sharing that. And again, thank you for your service. We really do appreciate that. Let me ask you this question that we ask most all of our guests here on the Talking Hope podcast, what does hope or the concept of hope mean to you?

Dr. Hugen: When I think of hope and how I use it on a daily basis, I hope it doesn't rain, I hope this meal tastes good. And I think that's more of just the desire. When I think about the word hope, it's a desire plus an expectation. And I think that when we hope for something, in particular, in this narrow focus of cancer, I think our patients are coming to us with hope that not only a desire for a cure, but an expectation. There's an underlying expectation that they come here and that they're going to receive the best treatment possible in this community of hope, where I frequently hear from the people who greet you at the door, to our cafeteria staff, to the nursing, to the doctors, to the executives, there's a spirit of hope and not just a treatment, not just a, we're going to see you and treat your disease, but we have hope, we have desires and expectations, and we hope that those match our patients who come in. So I think that's what hope means to me, is desire plus an expectation that something is going to happen.

Darrin Godin: Desire plus expectation, that is great. Thank you, Dr. Hugen, as we bring this episode to a close, what are your recommendations for our listeners today?

Dr. Hugen: I would say that, a few things, everyone has an opportunity to continually improve their life. And talking about lifestyle changes, that's a very almost flippant thing to say, but really focusing on what can I do today to help my future life? And whether that's making small changes, whether that's going for a walk, whether that's starting an exercise program, whether that's changing the way you eat just a little bit, whether that's cutting back on a drink that you would normally have, whether that's two drinks a day, cutting it to one, like small little steps can drastically improve your overall health. I would say another thing is don't ignore those symptoms.

When they happen, act on those. I'm guilty of it too, probably more so. I think doctors probably ignore symptoms in their own life, probably as much as the general population, if not more. But go seek an opinion. The worst thing that can happen is someone says, look, we can't find anything wrong. This is good news. And I think, finally, that if you do get a diagnosis of cancer, get that second opinion. I would seek out care where people do this day in and day out. This is their passion. This is what they do for a living. This is not, I see this diagnosis once every three or four weeks. You want to get seen by someone who does this on a daily basis. So getting a second opinion at a place that provides expertise in your area of malignancy.

Darrin Godin: Well, thank you, Dr. Hugen. Urologic cancer, like any cancer, is never easy but it starts with hope. As a leader in exceeding national survival rates, City of Hope is all in on ending cancer. Together, our 600 cancer physicians, 1,000 researchers and scientists, and our 800 cancer-focused clinical trials are what drive us forward. First in prevention, first in treatment, first in survival, when it comes to cancer, it's hope first. So thank you all for listening, and please join us on the next episode of Talking Hope.

Dr. Hugen: Thank you very much.