Bladder Cancer Update & Renal Cell Cancer Update, 2017 (Video Program)Neoadjuvant treatment of UBC
3:27 minutes.
TRANSCRIPTION:
DR PLIMACK: It’s an interesting story. So neoadjuvant chemotherapy, the first clinical trial looking at this was designed in the 1980s and launched in 1987 and took about 11 years to complete. It was a large SWOG trial. And it compared patients who had neoadjuvant chemotherapy using an old regimen we don’t use anymore called standard MVAC compared to up-front cystectomy. And it looked at overall survival. And when we look back at that data, the difference in overall survival was 2.6 years favoring the group that received neoadjuvant chemotherapy. So that, I mean, in the history of trials, really, to have a benefit measured in years in terms of survival, I think, is pretty impressive. And when we looked, we feel that was because we really increased the rate of patients who were cured with cystectomy, we think by cleaning up micrometastatic disease, but we know by cleaning up the disease in the bladder. Because when we go to surgery, a much larger proportion of the patients who received chemotherapy had no visible cancer left in their bladder when it was removed. DR LOVE: So, for example, if you compare the impact of adjuvant therapy to neoadjuvant therapy, how would it compare? DR PLIMACK: So we do that a lot in bladder cancer, because, I think, in some ways, it’d be easier just to go through the surgery from a referral pattern standpoint and then give the chemotherapy afterwards. But we learned a few things. One is that we lose a lot of patients after surgery to chemotherapy. They don’t recover in time to get it. And giving the chemotherapy before surgery is a lot easier on the patients than trying to give it after surgery. So we lose people before they could even enroll in an adjuvant trial. Then, when we compare the adjuvant trials, although many of them show a trend towards benefit with adjuvant therapy, none show the same definitive overall survival benefit that we saw with the neoadjuvant. And so in the field, it’s the NCCN recommendation that, if you’re going to give perioperative therapy, it’s far preferable to give it first. DR LOVE: What are the situations where you wouldn’t want to use it, or would, either way? DR PLIMACK: In the neoadjuvant setting, I think people — so some patients go to cystectomy for high-grade T1 bladder cancer, so not quite muscle invasive. And right now, the NCCN recommendation is really to limit it to muscle-invasive bladder cancer. I know many of us who practice will look at risk features aside from just pathologic stage when deciding, and so we will give some patients neoadjuvant if they have lymphovascular invasion or a micropapillary pattern that makes us concerned that we’re understaging them. Other patients who aren’t candidates for neoadjuvant chemotherapy are folks with poor renal function. And we, at our place, define that as a creatinine clearance that’s measured with a 24-hour urine of less than 50. And so for those patients, the risk of cisplatin-induced nephropathy, we feel, is too high to warrant cisplatin-based neoadjuvant therapy. DR LOVE: What about neoadjuvant therapy with carbo? DR PLIMACK: So the NCCN Guidelines actually released a statement on that, that it really shouldn’t be done. If you can’t give cisplatin — we know that cisplatin is more effective than carboplatin in other comparative studies. There’s no evidence to show that perioperative carboplatin achieves the same benefit. And if you’re not going to achieve the same benefit, especially in the neoadjuvant setting, you are delaying surgery, right? So it was felt in the wash that if perioperative therapy will be given, it should be with cisplatin. |