Topic: Advanced Disease

Point-Counterpoint: Erectile Dysfunction After Local Therapies: PDE5 Inhibitors and Early Penile Rehab Improves ED Recovery Following Radical Surgery – Pro

Point-Counterpoint: Erectile Dysfunction After Local Therapies: PDE5 Inhibitors and Early Penile Rehab Improves ED Recovery Following Radical Surgery – Pro

by | Jun 2023

T. Mike Hsieh, MD, MBA, presents the pros of using PDE5 inhibitors and early penile rehabilitation to treat erectile dysfunction post-radical prostatectomy. In this presentation, Dr. Hsieh discusses, the role of tissue hypoxia in recovery failure, the changing ratios of collagen versus smooth muscle in the organ pre- and post-operation, and why Restoration of QoL, not Spontaneous Erection Recovery, should be the measure of success.

This lecture is part of a Point-Counterpoint debate. Its opposing lecture is “Point-Counterpoint: Erectile Dysfunction After Local Therapies: PDE5 Inhibitors and Early Penile Rehab Improves ED Recovery Following Radical Surgery–Con.”

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Risk-Adapted TURBT

Risk-Adapted TURBT

by | Feb 2023

In this 20-minute video, Seth P. Lerner, MD, Professor of Urology and Vice-chair for Faculty Affairs in the Scott Department of Urology, and Director of Urologic Oncology and the Multidisciplinary Bladder Cancer Program at Baylor University, discusses risk-adapted transurethral resection of bladder tumor (TURBT). He assesses TURBT’s role in staging and treatment and considers its use in bladder preservation.

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Bladder Sparing Tri-Modal Therapy Updates

Bladder Sparing Tri-Modal Therapy Updates

by | Feb 2023

In this 24-minute video, Daniel A. Hamstra, MD, PhD, Professor and Chair of Radiation Oncology at Baylor College of Medicine, discusses the viable but under-utilized therapy of trimodal bladder preservation. He specifically explores the role of surgery, chemotherapy, radiotherapy (RT), and check-point inhibitors in bladder sparing therapy.

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Point-Counterpoint: Neoadjuvant Chemotherapy Prior to Cystectomy – Con

by | May 2022

Taking the con side in a point-counterpoint debate, Alan H. Bryce, MD, Medical Director of the Genomic Oncology Clinic at Mayo Clinic Arizona in Scottsdale, argues that offering neoadjuvant chemotherapy (NAC) to patients with invasive bladder cancer prior to radical cystectomy (RC) may not always be the appropriate decision. He begins by considering what the debate even is, explaining that the NCCN considers NAC followed by radical cystectomy a category 1 recommendation based on high level data. Meanwhile, Dr. Bryce notes, adjuvant chemotherapy is only considered a category 2A recommendation. However, he continues, the NCCN guidelines also mention that patients with “hearing loss or neuropathy, poor performance status, or renal insufficiency may not be eligible for cisplatin based therapy,” and if “cisplatin based therapy cannot be given, neoadjuvant therapy is not recommended.” Dr. Bryce also argues that while clinical trial data strongly favors NAC, real-world patient populations are different from trial populations. He cites a study based on real-world data which found that the patients in the SWOG trial of NAC were younger and fitter compared with national numbers, and which found the survival benefit with NAC to be slight in retrospective data. Additionally, Dr. Bryce observes that about 33 to 41% of patients are ineligible for cisplatin due to their baseline renal function status. He notes that those patients might benefit from adjuvant chemotherapy, but acknowledges there have been few randomized controlled trials in this setting. Dr. Bryce then highlights toxicity issues related to NAC, including increased creatinine, decreased neutrophil, peripheral sensory neuropathy, and tinnitus. He concludes that because real-world patients are older and have more comorbidities than trial populations, NAC perhaps should not be used as widely as guidelines indicate.

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Bladder-Sparing Trimodality Therapy

by | Mar 2022

Daniel A. Hamstra, MD, PhD, Chairman and Professor of Radiation Oncology at Baylor College of Medicine in Houston, Texas, discusses bladder-sparing trimodality therapy for patients with bladder cancer, explaining the role of each aspect of care, outcomes in terms of quality of life, and the potential future role of checkpoint inhibitors. He begins by noting that successful organ preservation approaches in oncology are common (e.g., in breast cancer, head and neck cancer, and extremity sarcoma) and can reasonably be applied to bladder cancer as well. Dr. Hamstra then introduces the standard care pathway for trimodality bladder preservation, from transurethral resection of bladder tumor (TURBT), to neoadjuvant chemotherapy, to radiotherapy with radiosensitizing agent, to follow-up with repeat cystoscopy. He goes into detail about the role of each portion of treatment, arguing that surgical management, concurrent chemotherapy, and radiation therapy are all critical to treatment success. Dr. Hamstra also discusses how radiation should be delivered in terms of effectiveness and toxicity and considers the question of whether to treat the bladder only or the pelvis and bladder with radiation. He then looks at patient-reported quality of life after bladder preservation, highlighting that while many patients report declines in bladder-related quality of life immediately following chemoradiotherapy, they generally improve to baseline after 6 months, and ⅔ of patients report stable or improved quality of life on long-term follow-up. Finally, Dr. Hamstra touches on future additions to bladder-sparing treatment such as checkpoint inhibitors, highlighting the ongoing INTACT trial of concurrent chemoradiation with or without atezolizumab for localized muscle invasive bladder cancer. He concludes that trimodality bladder preservation represents a viable but underutilized option for T2-T4 bladder cancer that requires coordinated care between urology, medical oncology, and radiation oncology. Dr. Hamstra reiterates that each component of treatment is critical, quality of life outcomes are excellent, and newer agents may also improve outcomes.

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Neoadjuvant vs. Adjuvant vs. None – “Perioperative Therapy”

by | Feb 2022

A. Edward Yen, MD, Assistant Professor of Medicine in the Hematology and Oncology Section at Baylor College of Medicine in Houston, Texas, summarizes research on perioperative therapies for bladder cancer and how they compare to each other. He begins with an overview of the current standard of care for muscle-invasive bladder cancer (MIBC), citing a Swiss study showing that after radical cystectomy there is still a problem of incurable disease relapse through overall survival rates below 63%, and another study showing that neoadjuvant cisplatin-based chemotherapy (NAC) combinations improve survival for MIBC by 5-8%. Dr. Yen then overviews NAC, highlighting the VESPER trial that compared cisplatin-gemcitabine (GC) and dose-dense MVAC (ddMVAC) in the perioperative MIBC setting and found that more patients were able to follow through with NAC than adjuvant chemotherapy (AC) by 21%. He discusses multiple immunotherapy trials that together show that patient responses seem better with chemo-immunotherapy than they do with immunotherapy alone. Dr. Yen then reviews the CheckMate-274 trial that found that adjuvant nivolumab treatment-related adverse effects were tolerable due to a 7% rate of being severe enough to end treatment vs. a 1.4% rate in the placebo arm. He also summarizes the IMvigor trial, which did not meet its primary endpoint of disease-free survival but found that positive ctDNA patients had an improvement from atezolizumab that was not seen in other patients. Dr. Yen concludes that GC and ddMVAC remain important perioperative chemotherapy regimens, that neoadjuvant and adjuvant therapies have situational uses, and more research will be key to refining these treatments further.

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