Bladder Cancer Update & Renal Cell Cancer Update, 2017 (Video Program)Chemotherapeutic regimens commonly used in the neoadjuvant and adjuvant settings
3:31 minutes.
TRANSCRIPTION:
DR PLIMACK: No one gives standard MVAC anymore. It was invented before growth factors and before ondansetron, so before antiemetics. And it was extremely difficult to give. And no one would design a chemo regimen this way now, the way we get chemo on day 22 and then have to start again on day 1. So that’s been replaced by 2 different regimens. One is gemcitabine and cisplatin, and the data for that is also very old — it’s data taken from the metastatic setting where gem/cis was equivalent to standard MVAC but better tolerated. There’s been no perioperative prospective evaluation of gemcitabine and cisplatin. MVAC, however, has been converted to a more modern regimen called dose-dense or accelerated MVAC. And we and others have published prospective trials looking at that regimen and found it to be very efficient. It’s a 2-week regimen, so 3 cycles can be given in 6 weeks and you’re done — safe and as effective as the standard MVAC given in the past. So now those are the 2 regimens most often used in the neoadjuvant and adjuvant setting. DR LOVE: And to what extent are they being utilized? To what extent has this research actually moved into practice? DR PLIMACK: Right. So I think with the advent of these more tolerable regimens more and more, there have been surveys over time. And I would say even as recently as 5 years ago, only about a third of patients were even offered or considered for neoadjuvant chemotherapy. Now I think, (1), we’re getting the word out about it. Two, there’s more interest, in general, in bladder cancer because of the developments in the metastatic space. I think people are reading up on it and kind of learning about it more. And (3), we’re really showing in prospective trials that we can do this faster and better than it was done in the ‘80s, which shouldn’t be a surprise, right? I mean, we’ve made a lot of progress. We can give chemo better, too. DR LOVE: I’m guessing to whatever extent it’s being underutilized, the obstruction would be in the referral to the medical oncologist as opposed to the patient coming to the medical oncologist and the medical oncologist saying, “No, I’m not going to do it.” But you tell me. DR PLIMACK: So there have been surveys about this. And so they’ve elucidated a lot of the different reasons. I think one is a fear of, quote-unquote, delay to surgery. And whether that’s on the part of medical oncology or urology, you’re probably right: mostly urology. But I think, honestly, both. What we have to do is educate. And what we tell our patients is, “We’re not delaying your treatment. Your treatment consists of this package, which is chemo and surgery that we know will give you the best chance of cure. And your treatment starts as soon as we place that IV and give you your first dose of chemotherapy.” So it’s not a delay. And we have to work against that. There are some other feelings about it that have come out in surveys. One is, I think for a long time, there was the thought that, “Why waste time, neoadjuvant? We can just give it adjuvant to people who need it.” And I think the adjuvant trials have not shown the same benefit as the neoadjuvant. And so that has eroded away. And the other one is the idea that we can stage people well with bladder cancer. So bladder cancer is a very difficult disease to stage in terms of initial staging, because measuring the depth of involvement in the bladder is not something that can be done very well with imaging. And so we found at Fox Chase when we looked at patients who we thought had just muscle-invasive disease, they actually were upstaged 75% of the time. So knowing that we’re bad at staging and knowing that we understage patients has also counteracted this perception that we can tell in advance who needs it and who doesn’t based on stage. We really can’t. |