European Urology Today Official newsletter of the European Association of Urology
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Vol. 30 No.3 - June/July 2018
2018 EAU National Societies Meeting
ESUT18 in Modena
The Future is Female
Two-day meeting addresses common concerns in urology
Read about the revolutionary three-screen live surgery meeting
Congress examines growing female role in surgery
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BCa18: Challenges in standard practice amid new changes Munich meeting provides in-depth assessment of strategies and emerging options By Joel Vega
8-9 June 2018 Munich, Germany
The treatment landscape of bladder cancer, one of the most lethal urological malignancies, is evolving at such a fast pace that specialists encounter clinical dilemmas and challenges which prompt them not only to re-assess current guidelines but also to anticipate new therapeutic options that may enable the delivery of optimal care.
www.bca18.org which is biased by poor data quality and the low level of evidence in the guidelines,” he explained.
Following the launch of a dedicated prostate cancer update meeting last year in Vienna, the EAU Update on Bladder Cancer (BCa18) is the first meeting on bladder cancer to be offered by the EAU with the aim to educate cancer experts across Europe and beyond. With 275 participants, including faculty and exhibitors, from around 48 countries, some of the cancer experts came from as far as China, Burkina Faso, Mexico and South Africa. From across Europe, host country Germany accounted for many of the participants, with Italy, the United Kingdom, Austria and Spain also BCa18 gathers nearly 300 participants in Munich for the latest in bladder cancer updates amply represented by urologists and other medical specialists. “We are moving forward. We now have a lot of new Rodolfo Montironi (IT) discussed the WHO 2016 Held in Munich from 8 to 9 June, the meeting had a biological predictors that are not yet confirmed in classification. “The correct characterisation of the compact format with succinct overview update non-invasive and invasive neo-plasms has diagnostic, prospective randomised trials, but probably are lectures preceding the interactive breakout case prognostic and therapeutic implications, significantly going to be implemented in the decision when discussions to allow a more inclusive and direct giving new adjuvant or neoadjuvant therapies in impacting management of individual patients,” he exchange between faculty and the participants. With a said. Ashish Kamat (US) presented a concise overview muscle-invasive disease,” Bellmunt said. “There is point-by-point review of standard treatments and a on immunotherapy in NMIBC and underscored its role more data coming up about the benefits of giving, voting system on key questions that test the for example, adjuvant chemotherapy in patients to further boost multidisciplinary partnership. He who fail new adjuvants. This means we switch to knowledge and clinical practices of the participants, added there are still hurdles to face and overcome in BCa18 is comprehensive and detailed. another type of chemotherapy. Although everything integrating immunotherapy in urology. is retrospective, not prospective. Perhaps in this way, we can select specific patients just to give The opening session on high risk non-muscle invasive Among the issues he mentioned are the urologist’s capability to maintain an applicable patient additional therapy, and maybe we can improve the bladder cancer (NMIBC) brought to the fore key population, and the clinical appropriateness of outcomes,” he added. questions such as the relevant changes needed in practice setting and demographic considerations. both the EAU and ESMO guidelines on NMIBC with Educational (CME) strategies and adaptability within Necchi, meanwhile, described the treatment Dr. Joan Palou (ES) tackling issues such as the landscape as “continually evolving” and said that in discrepancy between guidelines adherence and actual an evolving treatment landscape also present their own challenges. the next 18 months agents such as ramucirumab, clinical practice. durvalumab, pembrolizumab, atezolizumab, “In a 2017 study by Hendriksen (Eur Urol Focus, 2017), “Urologists should be not too guarded or shy of being avelumab, and nivolumab are the drugs to watch. part when it comes to systemic immuno-oncology These agents are undergoing testing in various trials 87% of the respondents say they use the guidelines, and results are to be expected in the following management. It is a multidisciplinary effort, it is but only 40 to 69% correctly identified prognostic months, with nivolumab’s expected outcomes by the teamwork and we have to collaborate with the factors. Re-TURBT were performed in low risk last quarter of 2019. medical oncologists. Another message is that these patients,” said Palou. “There is over-monitoring of are our patients for which we have been doing the low-risk and under-monitoring of high risk,” he Necchi’s key messages included the role of PD-L1. follow-up and surveillance. It’s not fair to patients added to illustrate the gap between observing the “PD-L1 should be tested with clinical assessment as that since the immune-oncology is administered by guidelines and actual clinical practice. there is value for both mono and combo in PD-L1 someone else, we send them somewhere. The high patients, determined by tolerability concerns, patients would feel lost,” Kamat said. Palou took up risk strategies, transurethral resection and value for combo in PD-L1 low patients,” he (TUR), adjuvant chemotherapy and T1-High grade Surgical and systemic approaches in MIBC pointed out. During the case discussions on disease, among others. “Re-TUR may not be necessary in patients with T1HG/G3, if muscles muscle Following the case discussions, the afternoon session neoadjuvant and adjuvant therapies, Necchi said moved on to surgical and systemic approaches in adjuvant chemotherapy is the first option that tissue is present in the specimen. There are no muscle invasive bladder cancer (MIBC) and advanced should be offered to patients. “There are multiple differences in recurrence, progression and cancerdisease, with Joaquim Bellmunt (ES) assessing the clinical trials available in chemotherapy. Clinical specific survival (CSS), “ he said, noting the initial guidelines on MIBC and Andrea Necchi (IT) tackling trials should be the first to be offered after the first rational for re-TUR is due to the high number of new drugs and therapeutic sequences in locallyintervention instead of the usual chemotherapy tumours left behind after the first re-TUR. Until there advanced stages. is more evidence, we have to re-TUR T1 tumours, which is mandatory to improve the first TUR. An estimated 75% of bladder cancers are nonmuscle-invasive bladder cancer, and the remaining “Doing a better first TUR is more important. We can are either muscle-invasive or metastatic disease, a avoid in the near future to re-TUR so many patients with T1 disease. If we have a patient with a solitary or stage where the disease becomes lethal. For MIBC, Bellmunt said neoadjuvant chemotherapy (NAC) is the a small tumour, and perform a good first TUR with current standard, but the guidelines of both the EAU this patient, then a second TUR is probably not needed. These factors reduce the number of re-TURs, and ESMO are still lacking when it comes to issues a procedure which also has a psychological impact on such as the management of variant histologies. “There is also the lack of predictive biological factors patients,” he explained. for NAC in both guidelines,” said Bellmunt. In the ESMO Guidelines, there are suggested options after NAC failure, whereas in the EAU Guidelines these are missing. He also noted that there is a lack of integration on the management of upper urinary tract (UUT) tumours in the EAU Guidelines, while in the ESMO these are not addressed at all. Despite these gaps, he noted the prospects in new biological markers. June/July 2018
Prospects in molecular classification and immunotherapy On Day 2, urologist Seth Lerner (US), oncologist Thomas Powles (UK) and urologist Maurizio Brausi (IT) took up new developments in bladder cancer classification and treatment. Lerner tackled genomics’ impact on clinical practice, Powles discussed immunotherapy’s role in metastatic BCa, and Brausi examined palliative management issues in unresectable MIBC tumours. “MIBC is associated with a very high mutation rate… and the mutation processes affect survival,” said Lerner in his lecture in which he covered topics such as expression-based molecular subtypes, upper urinary tract tumours, prognostic biomarkers and how it may inform clinical decision-making. “mRNA expression-based subtypes define unique biology and treatments,” said Lerner as he underscored that high mutation numbers are linked to survival rates. “These fusions may render a patient sensitive to targeted therapy,” he added. Powles discussed immune checkpoint inhibitors licensed in metastatic urothelial cancer such as IO, atezolizumab, nivolumab, pembrolizumab, durvalumab and avelumab- drugs with PD-1 and PD-L1 as targets for inhibition. On single-agent immune therapy in platinum refractory disease, Powles mentioned the following key points: • Immune checkpoint inhibitors have superseded chemotherapy in platinum-refractory disease; • All of the drugs are associated with long-term durable remission; • Pembrolizumab is the only agent with a positive randomised phase 3 study; and • The biomarkers are 'consistently' inconsistent. Continued on page 22
7-9 February 2019, Berlin, Germany Page 19
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