How will immunotherapy change the future of bladder Ca care?

Urology Times reached out to three urologists (selected randomly and asked them each the following question: How will immunotherapy change the future of bladder Ca care?

Dr. Dickstein“It’s an exciting time in bladder cancer because for many years we’ve really had no improvements and no progress. Now we have something to hold onto that’s actually viable.

This isn’t the end of the story for bladder cancer; it’s just the beginning. These drugs are being used in lots of different stages: in the metastatic setting, the neoadjuvant setting prior to radical surgery, and now even with patients who have failed bacillus Calmette-Guérin (BCG) with nonmuscle-invasive bladder cancer. So there’s a lot of potential use for these drugs; it’s really an exciting time.

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If you look at sheer numbers, more patients have nonmuscle-invasive bladder cancer. So if successful, that’s where it will impact the most patients. But advanced pre-surgical and metastatic cancer is really where it can have more of an impact on quantity of life for individual patients. In the more advanced cancers, I think it will have a greater impact on a smaller number of patients but will make a bigger difference in their survival. We’re not talking cures, but we are talking a significant impact on survival outcomes, which are pretty terrible for patients with metastatic bladder cancer so far.

The treatment of metastatic cancer is seeing that impact now, while the other stages are still in clinical trials, so it may be a good 3 to 5 years out before we see the full impact.”

Rian Dickstein, MD

Hanover, MD

Next: “Our specialty is just hitting the tip of the iceberg with immunotherapy."

Dr. Bivins“Our specialty is just hitting the tip of the iceberg with immunotherapy. We’ve had a taste of it in prostate cancer and we know the benefits. Now we’re seeing it in advanced bladder cancer. Patients are experiencing longer survival when treatments utilize the immune system to kill cancer. We’re very excited about that.

We’re seeing its usefulness for advanced or metastatic bladder cancer patients who would either receive chemotherapy; or patients who don’t qualify for chemotherapy or who can’t tolerate, or aren’t candidates, for chemotherapy.

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As urologists, we’re not primary administrators of immunotherapy; it’s the oncologists. But to be able to add an additional treatment arm to these diseases is very exciting. We have an oncologist in our group so it’s a natural fit, but some urologists will get involved in immunotherapy. It is something urologists can do. We’ve had experience with immunotherapy for prostate cancer, so it’s something we may be able to place in our armamentarium of treatment options.

Typically, these patients are already seeing oncologists or are being evaluated by oncologists, but I do think it’s something we could offer. If urologists are confident giving immunotherapy and understand how it works, the complications and how to deal with them, then that’s fine. At the end of the day we just want to be able to give patients the best care.”

V. Michael Bivins, MD

Birmingham, AL

Next: "Urologists have become more comfortable with the concept of immunotherapy"

Dr. Corman“Urologists have become more comfortable with the concept of immunotherapy for urologic cancers in the past decade. If you really think about it, urology’s experience with immunotherapy predates prostate cancer by more than 2 decades.

First, we actually use immunotherapy for bladder cancer every day-BCG treatments. Even though we may not think of it as that, that’s exactly what BCG is. Going back even further in time, we’re also experienced with immunotherapy for advanced renal cell carcinoma, using interleukin-2. So the concept of immune therapy isn’t really foreign for urologists.

Now there are some relatively new immune agents for advanced bladder cancer that is refractory to chemotherapy. Promising studies indicate that select patients may see benefits to immune stimulation. There are also bladder cancer vaccines that can take the form of a true vaccine.

So urologists are becoming more accustomed to the idea of giving therapy before surgery or radiation to make those treatments more effective. We’re more accepting that chemotherapy before removing the bladder can make those surgical outcomes better.

Agents recently FDA approved for immunotherapy for bladder cancer show that patients who had minimal recourse after failing chemotherapy now have additional options available. These add to our armamentarium, and urologists want to be involved in this. We know this disease, we treat this disease, and these are agents that can be given by urologists in the right setup.

With our history of immunotherapy for prostate cancer, this is not asking people to reach far outside of their comfort zone.

Currently, immunotherapy has its biggest bang in early disease to prevent progression, but so many options are available for early-stage patients, more resources may actually get dedicated to advanced bladder cancer because those patients have fewer options. A recent drug out of MD Anderson that was FDA approved saw 20% of the patients have a partial or complete response. For people who are end stage that’s pretty remarkable.”

John Corman, MD

Seattle

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