Bladder Cancer Update & Renal Cell Cancer Update, 2017 (Video Program)Selection of first-line therapy for metastatic UBC
3:11 minutes.
TRANSCRIPTION:
DR LOVE: So how was he managed then? DR GALSKY: So he was managed initially with what could be considered standard treatment. He received dose-dense MVAC. Now, dose-dense MVAC we more commonly use in the perioperative setting these days, although in a young patient with really lymph node-only or predominantly lymph node metastatic disease, it’s a regimen that’s not unreasonable. He received that treatment and, like a large proportion of patients, had a good response, with an objective response to treatment. DR LOVE: How would you have approached the same situation, if he’d been 75, 80 or 85? DR GALSKY: So in an older patient with a similar distribution of disease, really I look at 2 things, their functional status and their kidney function. There are patients within that age range who I would consider an aggressive regimen like this, like dose-dense MVAC, although the majority of patients realistically don’t receive that treatment. And more commonly these days, if I feel like I can administer a cisplatin-based regimen, it’s going to be split-dose gemcitabine and cisplatin. What I mean by that is giving gemcitabine on days 1 and 8 at 1,000 mg/m2 and then cisplatin at 35 mg/m2 on days 1 and 8. And that treatment’s recycled every 21 days. This specific regimen has been studied prospectively in a small Phase II study in bladder cancer but really showed results that were pretty comparable to what’s achieved with the more standard dose and schedule. And this trial enrolled patients with a creatinine clearance of 40 and above and was really shown to be pretty safe in patients with borderline kidney function. DR LOVE: So what was the next step in this man’s course? DR GALSKY: So he had a good response to treatment. And really what we do as standard of care in patients with metastatic urothelial cancer, after receiving 6 cycles of treatment, provided that they haven’t had disease progression and they tolerated treatment relatively well, we stop treatment and we wait. And so that’s what happened. He completed treatment and then went on a surveillance schedule, surveillance scans. And typically we do scans every 3 months in that setting. And he had a response to first-line treatment that lasted fairly long, about a year, and then subsequently developed disease progression in the adrenal gland, in the lungs and progressive lymphadenopathy. DR LOVE: So nowadays I would imagine he would have gotten a checkpoint inhibitor at that point, but he got more chemotherapy. DR GALSKY: That’s right. That’s right. He got additional chemotherapy using drugs that are commonly administered in this setting before the immune checkpoint blockade era. And he received treatment with gemcitabine, now commonly used in the first-line setting, although he had not received the treatment before, and then treatment with a taxane, with docetaxel, and unfortunately didn’t really have good responses to those regimens. |