Immunotherapies in Treatment of Bladder Cancer - Episode 7

Frontline Therapy for Non-Metastatic Muscle-Invasive Bladder Cancer

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Frontline treatment approaches recommended by urologists and medical oncologists for patients with non-metastatic muscle-invasive bladder cancer.

Leonard G. Gomella, MD: Petros, could we talk a little bit about non-metastatic muscle-invasive bladder cancer? What are different approaches short of? As Dr Chang I think mentioned, our guidelines all basically say when you’re in trouble default to cystectomy and that’s in the guidelines all over the place. Again, we know that it’s a pretty life-changing event. What do we have in the cooker, Petros, for the treatment of non-metastatic muscle-invasive bladder cancer?

Petros Grivas, MD, PhD: Thanks, Lenny. This is a very important question and I can tell you here at University of Washington Cancer Care Alliance that has the multidisciplinary bladder cancer clinic, which is a wonderful environment, one-stop shop for patients, we have this every Tuesday morning with 4 new patients at that time. We have urologic oncology. We have a medical oncology. We have radiation oncology, radiologist, pathologist, ostomy nursing, and advanced practice providers and the coordinator. We see the patient in a comprehensive way. We evaluate the films, scans, as well as pathology. We look at all those aspects of care and other medical comorbidities. I can tell you this is a really comprehensive evaluation resulting in a very concrete treatment plan for the patient by noon that day. We schedule any remaining evaluations, diagnostic tests at that time.

The majority of patients end up with a radical cystectomy, for men and with pelvic dissection ideally preceded by cisplatin-based chemotherapy, that’s how with level 1 evidences. We try to implement that level 1 evidence cisplatin-based neoadjuvant chemotherapy when we can. We have about, I would say, broadly about 20% of patients, maybe 10% to 20%, who may end up getting bladder preservation based on some clinical criteria we use.

We definitely incorporate the guidelines; NCCN [National Comprehensive Cancer Network] guidelines, ASCO [American Society of Clinical Oncology] guidelines, AUA [American Urological Association] guidelines in our decision-making and we individualize based on the patient characteristics. For example, for bladder preservation, Lenny, we take into account the size of the tumor, number of tumors, location. For example, is it in the trigone blocking the ureter, the component of the tumor, any component of ostensible diffuse carcinoma inside, hydronephrosis, any variant histology? As long as the bladder function, the capacity of the bladder, and the symptomatology from the bladder, all those factors come to play in this multidisciplinary decision-making. The other thing is clinical trials. We have plenty of clinical trials. That’s what we do both in the neoadjuvant/adjuvant setting around cystectomy but also in the field of bladder preservation. For example, the SWOG 1806 is a big example that many of us are a part of which is a huge effort from the NCCN looking at chemoradiation plus/minus a checkpoint inhibitor after max with the RBT [resection of bladder tumor]. So I think these are all great opportunities to improve upon our clinical trial offerings to the patients and incorporate clinical trials as options in the standard of care discussions. In that context we’ll discuss neoadjuvant therapies, adjuvant therapies, even if someone gets neoadjuvant chemotherapy of trial, we discuss it. We may think about the clinical trial adjuvantly, or potentially adjuvant nivolumab [Opdivo], which is now an FDA [Food and Drug Administration] approved option in the adjuvant setting. So all this happens in the context of a multidisciplinary clinic.

Leonard G. Gomella, MD: Thank you for that, and thanks for pointing out the importance of imaging and pathology. We have a pre-clinic in our multidisciplinary where we actually go over this including clinical trial. So Petros thanks for that overview.

Transcript edited for clarity.