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Historic Perspective on Bladder Cancer Treatment

Robert Dreicer, MD, MS, MACP, FASCO, University of Virginia Cancer Center
Published: Friday, May 05, 2017



Transcript:

Robert Dreicer, MD:
Among the most frequent questions I receive, both from physicians and patients, one is, “The next generation of therapies that are finally appearing on the scene, how does that fit into the paradigm of how we manage advance urothelial, or bladder, cancer?” As a senior oncologist, I’ve been around a long time. I think it’s really important to recognize that when I was a Fellow in oncology, cisplatin—its use in urothelial cancer—was just starting.

At the time, it was a revolution because there were really no therapies that were useful for this disease. All of a sudden, platinum-based chemotherapy, MVAC, and other regimens came along, and subsets of patients were responding to therapy, living longer—or at least appearing so. We were starting to see patients actually develop brain metastases. Nobody with advanced bladder cancer disease ever developed them because they never lived long enough to. So, there was a fair amount of enthusiasm associated with the development of these agents. The challenge, of course, is that 25 years went by without any changes. We got really good at using the therapies that we had, but we made no progress.

When we start seeing patients now responding to checkpoint inhibitors, and some of the patients who have really dramatic responses that are prolonged, this is really a major shift in the management of the disease. That’s the perspective I bring to what’s going on today in contrast to what we’ve been doing for 20 or 30 years.

One of the questions that I’m asked, not infrequently, by patients and their families is about survival time. Historically, for a patient who could get cisplatin-based chemotherapy, we talk about median survivals in the 14- or 15-month range. With next-generation therapies—the checkpoint inhibitors—we don’t really, fully yet have survival data. There’s only 1 presented phase III trial. What’s pretty clear, however, from the data that is actually in the public domain is that in some of the early trials—the phase II trials that led to the approval of drugs like atezolizumab and nivolumab—there are patients who do respond and are in sustained responses now approaching 2 years.

That’s unprecedented. Most patients don’t respond to these agents, so it’s a little bit hard to talk about survival in the big population. But in those patients who respond, we believe that there’s a tail on the survival curve—meaning, some of these patients may do well for very prolonged periods of time. It’s too early yet to fully appreciate that, but it’s unequivocally different than what we’ve seen before.

Transcript Edited for Clarity
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Transcript:

Robert Dreicer, MD:
Among the most frequent questions I receive, both from physicians and patients, one is, “The next generation of therapies that are finally appearing on the scene, how does that fit into the paradigm of how we manage advance urothelial, or bladder, cancer?” As a senior oncologist, I’ve been around a long time. I think it’s really important to recognize that when I was a Fellow in oncology, cisplatin—its use in urothelial cancer—was just starting.

At the time, it was a revolution because there were really no therapies that were useful for this disease. All of a sudden, platinum-based chemotherapy, MVAC, and other regimens came along, and subsets of patients were responding to therapy, living longer—or at least appearing so. We were starting to see patients actually develop brain metastases. Nobody with advanced bladder cancer disease ever developed them because they never lived long enough to. So, there was a fair amount of enthusiasm associated with the development of these agents. The challenge, of course, is that 25 years went by without any changes. We got really good at using the therapies that we had, but we made no progress.

When we start seeing patients now responding to checkpoint inhibitors, and some of the patients who have really dramatic responses that are prolonged, this is really a major shift in the management of the disease. That’s the perspective I bring to what’s going on today in contrast to what we’ve been doing for 20 or 30 years.

One of the questions that I’m asked, not infrequently, by patients and their families is about survival time. Historically, for a patient who could get cisplatin-based chemotherapy, we talk about median survivals in the 14- or 15-month range. With next-generation therapies—the checkpoint inhibitors—we don’t really, fully yet have survival data. There’s only 1 presented phase III trial. What’s pretty clear, however, from the data that is actually in the public domain is that in some of the early trials—the phase II trials that led to the approval of drugs like atezolizumab and nivolumab—there are patients who do respond and are in sustained responses now approaching 2 years.

That’s unprecedented. Most patients don’t respond to these agents, so it’s a little bit hard to talk about survival in the big population. But in those patients who respond, we believe that there’s a tail on the survival curve—meaning, some of these patients may do well for very prolonged periods of time. It’s too early yet to fully appreciate that, but it’s unequivocally different than what we’ve seen before.

Transcript Edited for Clarity
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