May 23, 2018 - father's case, in case there is microscopic cancer they can't detect? His oncologist ... mean that there'
Neoadjuvant & Adjuvant Chemotherapy for Bladder Cancer Part III: Questions & Answers May 23, 2018 Presented by: Dr. Matthew Galsky is a medical oncologist focused on the care of patients with bladder cancer. He received his medical degree from Tufts University School of Medicine and subsequently completed training in Internal Medicine at Beth Israel Deaconess Medical Center, Harvard Medical School. He completed a medical oncology fellowship at Memorial Sloan Kettering Cancer Center where he subsequently joined the faculty. In 2010, he was recruited to the Tisch Cancer Institute Ichan School of Medicine at Mount Sinai as Director of Genitourinary Medical Oncology where he is currently a professor of medicine. Dr. Galsky's research has focused on the clinical development of novel therapies for bladder cancer and team science based approaches focused on dissecting the mechanistic under findings of response and resistance to novel bladder cancer therapies with a particular focus on immuno-therapeutic approaches.
Question 1: “My 77 year-old, non-smoking father was diagnosed with muscle invasive bladder cancer. They said his lymphs are clear and there is no spread of cancer outside the bladder but he is undergoing neoadjuvant chemo with a full cystectomy to come. His urology tumor specialist said the survival rate for patients who get chemotherapy before surgery is 5 to 7% better survival rate with no improved after. Is neoadjuvant chemo being used as a preventative measure prior to surgery in my father’s case, in case there is microscopic cancer they can't detect? His oncologist and two specialists said there is no cancer outside the bladder.” Dr. Galsky: Yes, so that's exactly the case. As I mentioned, in some of the early slides, the absence of the spread of the cancer on a scan, which is what the care team is referring to, unfortunately, does not mean that there's not microscopic spread of cancer. Now, there might not be but because we don't have good tests to know that for sure, chemotherapy is given and sometimes it's phrased or it's framed as a preventative treatment and that's certainly one way of looking at it from a conceptual standpoint. I can see how that it's appealing to frame it that way. Another way to think about it is that it's treating microscopic cancer that might be there and if microscopic cancer is indeed there, then of course the goal of the chemotherapy is to eradicate that cancer. Question 2: Would patients with non-muscle invasive bladder cancer benefit from these therapies, assuming perhaps that there is a planned radical cystectomy? Dr. Galsky: So, there are two elements to that question that are important. One is whether or not systemic treatments administered intravenously have a role for non-muscle invasive bladder cancer. Historically, they haven't and historically treatments administered directly into the bladder have been
Neoadjuvant & Adjuvant Chemotherapy for Bladder Cancer Dr. Matthew Galsky
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favored in that situation. The reasons that they've been favored is, one, there are some very effective treatments in that context such as BCG. The second is that by administering treatment directly into the bladder there is limited systemic exposure to the treatment, therefore, less risk in terms of side effects. So, if a treatment can be administered definitively and effectively into the bladder itself locally, then that's generally the preferred route. In patients with non-muscle invasive bladder cancer, such as high grade T-1 bladder cancer, whether or not giving chemotherapy prior to surgery, neoadjuvant chemotherapy should be done is a very interesting question. Because, there have been challenges in accruing to clinical trials even for patients with muscle invasive disease, that's a very challenging question to answer definitively within the context of a clinical trial. But, I agree and important one, it's something that hasn't been explored definitively. These new classes of drugs, the immune checkpoint inhibitors are being actively explored in the context of non-muscle invasive disease. Mostly in trials enrolling patients who've already had BCG and BCG hasn't worked or stopped working. So, this is really one of the first classes of drugs administered systemically, intravenously that is making a strong push into non-muscle invasive disease. Whether or not those clinical trials will demonstrate sufficient safety and benefit to be integrated into our standard armamentarium, we'll have to see. Question 3: What do you see as the role of circulating tumor cells or circulating tumor DNA in the near future? Dr. Galsky: So, as I commented on a few times during the talk, one of our challenges in terms of optimizing or refining or individualizing treatment in the muscle invasive bladder cancer setting is the inability to detect microscopic cancer that spread. These technologies that you mention, circulating tumor cells and tumor DNA, of course, do have the potential to represent that microscopic spread process. So, there's a lot of potential promise there in applying those technologies to; A: determine who should receive chemotherapy prior to surgery and; B: to monitor patients after surgery for microscopic evidence of recurrence before there's clinical evidence of recurrence. So, very promising technologies in very early days in terms of whether or not these will prove to be beneficial in terms of clinical decision making. So, lots of work to be done there but these are certainly some of the more promising technologies in this specific clinical disease state.
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