Investigator Perspectives on Emerging Concepts in the Management of Genitourinary CancersNonresearch use of checkpoint inhibitors in bladder cancer
2:55 minutes.
TRANSCRIPTION:
DR LOVE: Are there patients that you see right now in your own practice who you can’t get on a trial who you would like to give these agents to? And have you attempted to give any of the approved agents, for example, to patients like that? DR PETRYLAK: Yes, I’ve had success in getting nivolumab for patients with bladder cancer. And I was also successful in getting it for patients with kidney cancer before the FDA approval. So we’ve applied and we’ve talked to the insurance companies, and there are some other programs that are out there that may actually offer some backup for patients as well. DR LOVE: That's interesting. Have you seen any responses outside a trial setting? DR PETRYLAK: Yes. DR LOVE: In terms of the question of people who aren’t eligible for platinum therapy, and, of course, I think about older patients or frail patients, first of all, have you attempted to use nivolumab, or a checkpoint inhibitor, off study for patients like that? DR PETRYLAK: No, I haven’t. That I have not done. DR LOVE: How often do you see that, that you have a patient you really don’t want to give chemo to? DR PETRYLAK: It’s probably about 30% of all patients, a patient who’s platinum ineligible. It accounts for 30% to 40% of all patients. Now, that’s a varying definition that includes neuropathy, congestive heart failure, hearing loss and, of course, renal dysfunction. So it’s probably pretty rare that there’s somebody who I can’t at least give single-agent chemotherapy to. If their performance status is so poor, I think they probably shouldn’t be treated with anything at that point. It’s unlikely they’ll respond. But again, I think we need to understand better the mechanisms before we start moving into the untreated patients. DR LOVE: In those patients you use single-agent therapy, which agent? DR PETRYLAK: Single-agent, I’ve used gemcitabine. DR LOVE: Hmm. What are some of the other issues out there — obviously, this is an extremely exciting one — that are being looked at in bladder cancer, in general, from a research perspective? DR PETRYLAK: So moving all the way up front to nonmuscle-invasive disease, we know that BCG is the standard of care for patients with CIS. And of course there are limited options once a patient fails BCG. Cystectomy, obviously, is one treatment we would like to avoid. But can these checkpoint inhibitors either enhance the activity of BCG or be used as salvage after patients have progressed on BCG? So that’s, I think, one very, very important research area. DR LOVE: So systemic, though, checkpoint inhibitors. DR PETRYLAK: Right, systemic checkpoint inhibitors. DR LOVE: Hmm. That's interesting. DR PETRYLAK: Then, of course, is the question of adjuvant versus neoadjuvant therapy. Unfortunately, we’ve not had an adjuvant trial that’s shown a survival benefit, although adjuvant therapy is used in certain high-risk patients. And then I think the third portion we’ve talked about is: How do we improve the role of systemic therapy in patients who are metastatic? So I think there are really 3 areas to focus on. |