ERAS in Bladder Cancer - Sia Daneshmand

April 15, 2019

Sia Daneshmand discusses the history of fast-tracked and streamlined post-operative cystectomy care for patients and associated improved outcomes in his conversation with Ashish Kamat. He details the development of the ERAS protocol and the significant milestones that have been realized in this journey to improved patient outcomes after cystectomy.

Siamak Daneshmand, MD Dr. Sia Daneshmand is currently an Associate Professor of Urology Keck School of Medicine USC with Clinical Scholar designation and serves as director of clinical research as well as the urologic oncology fellowship director. Dr. Sia Daneshmand earned his medical degree at the University of California, Davis and completed his residency at the University of Southern California (USC) followed by a two-year fellowship in Urologic Oncology at the USC/Norris Comprehensive Cancer Center. He spent almost 6 years at Oregon Health and Science University where he established the Section of Urologic Oncology as a center of excellence for the treatment of bladder and testis cancers. He was recruited to USC Institute of Urology in 2010 as Director of Urologic Oncology. Dr. Daneshmand’s main interests include bladder cancer, advanced kidney cancer, and testicular cancer. He has extensive experience in urinary diversion and reconstruction following surgical removal of the bladder (radical cystectomy) as well as nerve-sparing retroperitoneal lymph node dissection (RPLND) following chemotherapy for advanced testis cancer. He is one of the highest volume surgeons for this disease on the west coast. He has been selected as one of “True Experts” in the Testicular Cancer Resource Center web site. He also has extensive experience in the management of advanced kidney cancers with vena caval tumor thrombus involvement, as well as prostate cancer, retroperitoneal sarcomas and surgeries requiring replacement of the great vessels. He is a member of Alpha Omega Alpha medical honor society and has been designated one of the “America’s Top Doctors” for several years. He is an active member of the Society of Urologic Oncology, has presented over 150 abstracts at scientific meetings and has authored over 120 peer-reviewed articles, reviews, and chapters. He is a reviewer for numerous urology journals.

Ashish Kamat, MD, MBBS
Professor of Urology and Wayne B. Duddleston Professor of Cancer Research at MD Anderson Cancer Center in Houston, Texas.

Read the Full Video Transcript

Ashish Kamat: Hello and welcome. It gives me great pleasure to welcome Dr. Sia Daneshmand, who's Associate Professor of Urology and Director of Urologic Oncology at the Keck School of Medicine at USC California. Welcome, Sia.

Sia Daneshmand: Thank you very much. It's a pleasure to be here.

Ashish Kamat: So, Sia, tell me, you've done a lot of work when it comes to bladder cancer or the field, in general. When it's invasive, early stage, but some of the things that you are best known for, and I think that has made a huge impact to our patients is your role in championing ERAS for bladder cancer patients because that sort of gets left out in discussions, like major cancer meetings and discussion points, but I think it really, truly helps our patients. So, tell me a little bit about the history of how you got involved in it, the history of ERAS in general and then we'll go from there.

Sia Daneshmand: Sure, absolutely. Thank you for bringing it up. I think you're right. It has a huge impact. This is a cancer meeting, we talk about the cancer parts of it, the true impact on patient care after a cystectomy and after major surgery is very, very important to all of us. So, you know, looking back at the history, there have been efforts to do fast track and streamlined postoperative care for patients for a long time. Raj Pruthi was one of the first to look at these fast track protocols in order to decrease the hospital stay for the patients and improve the patient outcomes. I was extremely frustrated at postoperative outcomes for cystectomy patients for a long time and I thought, you know, there's got to be something we can do to decrease it.

And you start looking at the literature and there were things that colorectal surgeons were really doing in 2006 and '07, starting then, and improving outcomes, decreasing ileus rates, and it seemed like when we did one thing or two things, it really didn't make a huge impact. It was really combining a set of postoperative things that were so counter-intuitive to people at the time. Early feeding, I mean, like really early feeding, and use of no NG tubes, no bowel preps, everything that we had learned as part of our surgical training and dogma. I mean, it's amazing how much dogma there is in surgical literature and training. So, once you stepped away from that, looked at the literature and said, "Yeah, really, NGs don't help." Nasogastric tubes are not helpful in decreasing ileus rates and there have been randomized trials showing that. Early feeding is good, walking. 

And of course, I think one of the biggest advances came with the use of Entereg® and you were, of course, pivotal in running the Phase 4 trial that showed use of Entereg® with decreased hospital stay and that's alvimopan, which is a mu receptor antagonist that will decrease the ileus rates. We put all the literature together. We did our work and together, with my partner, Dr. Hooman Djaladat, we literally just one day said, "Okay, that's it. No bowel prep. No NG, Entereg®, early feeding," and it started working and this was about 2012. And so, from then on it was really abrupt change in our postoperative management and so we did the first 100 patients and then published our experience and we went from a hospital stay of eight days, historically, down to a median of four days and that's been sustained. So, over the next 500 cases that we've done, the median hospital stay has been sustained. And I think there's a limit to how much you can shorten that. We are sending some patients home on day three. Very rarely day two, the really young and healthy patients. 

But a huge paradigm shift in how we manage patients. The patient experience is much better, again no nasogastric tubes, the rate of ileus is so much lower. We went from 25% down to 6% and so we've got a really good handle, I think, on how to manage these patients. There's a lot more work to do, I think, to decrease complications.

Ashish Kamat: And I'm a big believer in ERAS as well and I'm going to ask you some questions that I get asked when I talk about ERAS in the U.S. or elsewhere. So, one of the questions I often get when it comes to ERAS is that with ERAS, are we simply just transferring the burden of care from the hospital to another facility? In other words, talk a little bit about the readmission rates.

Sia Daneshmand: Sure, great question and I think we get asked that all the time. Are we just pushing patients out earlier and then they're just getting readmitted. No, this has been looked at multiple times and the readmission rates which are high, I don't think we've made a major impact there yet. The readmission rates are anywhere from 22 to 25%. The point is, it's not higher. So, when you're sending the patients home on day three to four, they're not coming back, day six or seven. It's the same readmission rate as we've had historically. So, as far as postoperative home care, we've always sent the patients home with home health care. They have needs for their urinary diversion, whether it's a neobladder or an ileal conduit. So, that part hasn't changed. 

We are our center, do send patients home on IV fluids every other day to prevent the dehydration and the readmission. It's not really transferring the care to home. We had been doing that prior to 2012, our ERAS protocol and we noticed actually our readmission rates really haven't gone down significantly with that, but we are seeing at least less dehydration events come into it. So, the short answer I think is ... this is the long answer ... is no. I don't think we're shifting to home health, home care. 

Ashish Kamat: I agree and I think the point to be made there is that we're not sending patients home sooner than they're ready to go home. They're ready sooner. 

Sia Daneshmand: Exactly. Very, very good point and I think some of the critics have been ... you're just basically pushing out from the forces of whether it's the hospital or whether it's your motivation or whatever it is, but no, I mean, these are the same discharge criteria that we had used for any other patient, ambulatory, able to tolerate at least a liter of p.o. intake, pain under control, labs are normal and ready to go home. So, once you've met these objective criteria, then you're ready.

Ashish Kamat: The other question you often get, I'm sure, is "Well, what about ERAS with robotic cystectomy? Do we need ERAS when it comes to robotic cystectomy and between ERAS and robotics, which is better for the patient?”

Sia Daneshmand: That's a good question and a topic of an upcoming talk at the AUA. Again, the short answer is yes. ERAS works for both robotic and open surgery absolutely blunts the benefits that you may see with robotic surgery. In fact, when you compare open and robotic surgery, the length of stay is essentially the same. The problem has been all the robotic series in the past have always compared to historical, pre-ERAS open surgery series, but in the modern series, when you do a comparison, they're exactly the same, whether there's complication rates or hospital readmission rates. So, I think you need it for both.

Ashish Kamat: I know you've done studies on cost, as well. Could you enlighten our viewers into what are the cost implications of ERAS adoption?

Sia Daneshmand: Yeah, huge cost implications. Shorter hospital stay, obviously, translates into less cost for the patient; however, there is increased medication cost, mostly attributable to Entereg®, but it completely is overshadowed by the hospital savings, so yeah, we did a paper that we published early on in our series of hospital savings is approximately $5 million per 100 patients, so it's a huge cost savings, I think, for the patient.

Ashish Kamat: You know, this is a great conversation. I could go on forever, but we do have to close. In closing, could you enlighten the viewers, those that are thinking of dipping their feet into ERAS, the top five things they should do? If they can't do everything, what are the top five things they should do?

Sia Daneshmand: Okay, top five things, I think at least in the U.S., we mentioned Entereg® has got great randomized data to support it, no NG tubes at all or if you use it, you can take it out in the operating room. No bowel prep. Early ambulation and early feeding and by feeding, whether you do clears on day one, we do regular food on day one, food that is well-tolerated, so I think these are the top sort of five most commonly used ERAS components. 

Ashish Kamat: Great, thank you so much, Sia.  We'll have you back for a longer segment, I'm sure. 

Sia Daneshmand: Thank you.

Ashish Kamat: Thank you very much.

Sia Daneshmand: Appreciate it, thanks a lot.