Prof. Ashish Kamat (US) presented “Systemic versus intravesical drug from high-risk NMIBC naive from BCG”. He stated, “The standard of care for high-risk, high-grade NMIBC is BCG. It reduces the risk of progression. If you use BCG as the standard of care, the risk progression drops from 9.6% to 5.8% for high-risk NMIBC, and from 40% to 14.8% for very high-risk NMIBC.”

Systemic vs. intravesical therapies

Prof. Kamat also enumerated the therapy options for patients with NMIBC: intravesical (e.g. intravesical chemotherapy, enhanced drug delivery, vaccines, and gene therapy) and systemic (e.g. immunotherapy [IO], targeted therapy, radiation, and other).

To demonstrate when to consider BCG-naïve patients with high-risk NMIBC for systemic therapy. He provided a patient case of a 79-year-old patient who is a long-time smoker and has diabetes and hypertension. The tumour characteristics are as follows:

• Largest tumour cluster: 4 cm, widely invasive T1 high-grade (T1HG), with 5% micropapillary component
• Base of tumour: muscularis propria present, no tumour, carcinoma in situ (CIS) present
• Trigone tumour: 2 cm, T1HG, no CIS, no muscularis propria present
• Bladder neck/prostatic urethra: with CIS, stroma present, not involved

Prof. Kamat explained, “Clearly, this is the type of patient you’d recommend for radical cystectomy. However, if the patient refuses the procedure and is worried about systemic disease, combining a systemic agent such as IO with an intravesical therapy such as BCG makes the most sense. This is the kind of patient where I would consider adding systemic therapy and not just intravesical therapy. In my opinion, it’s not a debate between intravesical or systemic therapies, but when to optimise the best treatment for the patient.”

Active surveillance (AS) in NMIBC

AS in NMIBC is “lagging behind schedule” according to Prof. Paolo Gontero (IT). In his lecture “Active surveillance in NMIBC: myth or reality?”, he stated that there are less than 1,000 published cases in over 20 years.

Prof. Gontero pointed out that patients with recurrent low-grade Ta-NMIBC are the ideal candidates as there is a broad population of these potential candidates. He added that the accuracy of patients’ selection and follow-up may be hampered by suboptimal estimation of grading/staging and unreliable markers. Furthermore, current exit criteria are efficient but need to be more relaxed. There is negligible progression event and the duration is short.

Concerning NMIBC, the anticipated course for AS includes longer follow-up because the long-term impact of AS on the disease is still unknown. Prof. Gontero added, “Patients’ acceptance should be explored. There should also be a reduction of the unreliability of visual tumour appearance. In this respect, we can record videos of the procedures. We should also test AS against a competitive comparator such as office fulguration or chemoablation in the future.”

View the session recap and watch the full presentations on the EMUC23 Resource Centre.

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The EUPROMS results revealed that active surveillance had the best average Expanded Prostate Cancer Index Composite (EPIC) score in incontinence (100) and sexual function (57). Respondents, 2943 prostate cancer patients from 24 European countries who received treatment, also experienced less tiredness, insomnia, and pain or discomfort while under active surveillance in comparison with other treatments. This led to Mr. Deschamps’ logical conclusion: “When it can be applied safely, active surveillance should be considered the first treatment for prostate cancer.”

During the discussion, via the interactive feature of the congress platform, Mr. Deschamps received two questions about the difference between the EUPROMS study and a clinical study. “It is a different kind of survey that we did. We wanted to have a picture of what the real quality of life of men is after treatment,” he clarified. “I think that clinical studies should be taking the quality of life into account as well: as a primary endpoint, in fact. Of course it is also important to consider life extension when deciding to spend a lot of money on a new drug, but quality of life should always be an endpoint, too.”

In the same session, Prof. Jonathan Epstein (US) addressed the controversies and uncertainty that persist in prostate cancer grading and the first prostate cancer grading recommendations from the Genitourinary Pathology Society (GUPS) that focuses on these areas. Prof. Anders Bjartell (SE), chairman of the EAU Research Foundation (EAU RF), gave an update on the EAU RF trials in progress such as the PEGASUS study. He also touched on the PRECISION study, which became a game-changing trial showing the value of MRI before a prostate biopsy. The Nimbus study, which was stopped early due to safety reasons, was further discussed in the later session “New trials update.”

This session on GU cancer highlights was only one of the highlights of EMUC20 Virtual‘s first day. Covering a broad spectrum of topics in genitourinary malignancies, EMUC20 Virtual features speakers from all over the world. Unique about this first day was, characteristic of the year 2020, the roundtable about the impact of the Covid-19 epidemic on the management of GU cancers.

(Re)watch a session? All sessions are available on demand in the Resource Centre.

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