Panelists:Raoul S. Concepcion, MD, FACS, Urology Associates; Michael S. Cookson, MD, MMHC, University of Oklahoma Health Sciences Center; Daniel P. Petrylak, MD, Yale School of Medicine; Daniel I. Quinn, MBBS, PhD, FRACP, FACP, University of Southern California; Neal D. Shore, MD, FACS, Carolina Urologic Research Center; Charles J. Ryan, MD, UCSF Helen Diller Family Comprehensive Cancer Center
Raoul S. Concepcion, MD: This has been extremely informative. We have discussed several important scenarios in the treatment of genitourinary cancers. Before we end this discussion, however, I’d like to get final thoughts from each of our panelists; a summary, if you will. Mike?
Michael S. Cookson, MD, MMHC: We covered a lot of territory here. So, with respect to the castration-resistant disease, I would say we need to move therapies up. And the studies are being done for us to be able to do that. We don’t have to wait for bone metastases. We need better predictors of response, so we don’t treat patients without knowledge of if they’ll respond or not. I think consolidating, sequencing, and then the appropriate use of aggressive local therapy for the right patient is on the horizon; good news for patients and surgeons alike.
From the non-invasive bladder cancer standpoint, we talked about some of the barriers we have for the BCG-unresponsive patients, better ways to identify those patients earlier, the promise of some enhanced immune therapies that are coming down the pipeline, as well as some novel therapies, including thermotherapies, for some of the chemotherapy that we administer in the bladder that may hold promise.
For invasive bladder cancer, I’m really thinking about ways to target those patients. Again, we talked about tools to try and predict responsiveness based on the genetic profiling—that would be good—the importance of the urologist in making the referral for the neoadjuvant chemotherapy and then the excitement around salvage therapies or maybe frontline immune therapies for these patients who can often die of a lethal disease.
Raoul S. Concepcion, MD: Very nice. Dan?
Daniel P. Petrylak, MD: Mike really summed it up very well for castration-resistant prostate cancer. I’ll add that I think that the markers are the important thing for us to think about, particularly for care of our patients, as well as for new drug approval. The FDA still requires that a survival benefit be attained for a drug to be approved for castrate-resistant disease. And with the plethora of agents that are out there at this point, we need markers to start trials like we’ve done in lung cancer, where we’ve had an ALK mutation and then randomized those patients with a specific mutation to the standard of care versus an ALK-targeted drug. We need to do the same thing in prostate cancer. So, I think that’s where the future is going to be.
In bladder cancer, the future is very, very bright. Again, molecular markers are important. We now have newer treatments, such as immune therapy, that has activity in refractory disease. But, remember, that’s about 25% of all patients. And patients who are PD-L–negative can have a response rate, but they’re not particularly high, as we see with the PD-L1–positive patients. We need to develop newer therapies in that area. And whether that be cytotoxic treatments, other molecularly targeted agents, or combination immune therapy, I think the future is going to tell you what direction we’ll go.
Raoul S. Concepcion, MD: Great. And David?
David I. Quinn, MBBS, PhD: I don’t think I have much to add, but to observe that we now have a range of therapeutics in advanced prostate cancer. And we’re grappling with how to sequence them and how to use them. We need to get to the same place with urothelial cancer so that we look at optimal use of immunotherapy, combinations, novel chemotherapy agents, and targeted agents for specific biomarker-driven subsets of patients. And then we need to look at early disease. We are doing better with neoadjuvant chemotherapy. That produces a small, but significant, incremental response. I’m hoping that we’ll be able to look at the refractory patients to BCG and do better and have more patients able to keep their bladder and not have to go through surgery. So, I think the future is bright.
Raoul S. Concepcion, MD: Great. Thanks to all of you for your contributions, not only to this discussion, but to the management of our patients moving forward. On behalf of our panel, we thank you for joining us. We hope you found this peer exchange discussion to be useful and informative.