MIBC and EVP

[msbbc833]

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What in the world is going on these days with urologists/med oncs with EVP? They are in cohoots with each other and with EVP. In patients who decline surgery or are not candidates for cystectomy they are treating patients with TURBT followed by EVP.

Okay it has a 50% path CR rate, great. That doesn't make it a curative treatment. CRT has a 75% pCR rate. If you want to do EVP it should be followed by RT. No where does NCCN list EVP as cat 1 treatment for MIBC.

I had a patient refusing surgery who then progressed after on EVP. The urologist's response after his second or third TURBT "well he needs better systemic therapy". Um no, he needs RT immediately

Am I missing something?? Is this common?

 

[Fpg1245]

What in the world is going on these days with urologists/med oncs with EVP? They are in cohoots with each other and with EVP. In patients who decline surgery or are not candidates for cystectomy they are treating patients with TURBT followed by EVP.

Okay it has a 50% path CR rate, great. That doesn't make it a curative treatment. CRT has a 75% pCR rate. If you want to do EVP it should be followed by RT. No where does NCCN list EVP as cat 1 treatment for MIBC.

I had a patient refusing surgery who then progressed after on EVP. The urologist's response after his second or third TURBT "well he needs better systemic therapy". Um no, he needs RT immediately

Am I missing something?? Is this common?

That’s a new one.

Urologists treat evidence as a minor inconvenience where I am.

How about upfront cryo and adt for Gleason 8 Pca?

 

[medgator]

That’s a new one.

Urologists treat evidence as a minor inconvenience where I am.

How about upfront cryo and adt for Gleason 8 Pca?

Or hifu.

 

[OTN]

Hey at least they're referring to medonc rather than just giving it themselves. Progress?

 

[DrZap]

What in the world is going on these days with urologists/med oncs with EVP? They are in cohoots with each other and with EVP. In patients who decline surgery or are not candidates for cystectomy they are treating patients with TURBT followed by EVP.

Okay it has a 50% path CR rate, great. That doesn't make it a curative treatment. CRT has a 75% pCR rate. If you want to do EVP it should be followed by RT. No where does NCCN list EVP as cat 1 treatment for MIBC.

I had a patient refusing surgery who then progressed after on EVP. The urologist's response after his second or third TURBT "well he needs better systemic therapy". Um no, he needs RT immediately

Am I missing something?? Is this common?

Haven’t seen this

 

[Palex80]

Okay it has a 50% path CR rate, great. That doesn't make it a curative treatment. CRT has a 75% pCR rate. If you want to do EVP it should be followed by RT. No where does NCCN list EVP as cat 1 treatment for MIBC.

It's a bit more complicated.

Yes, CRT can have a very high pCR rate. But 75% is rather high.
RAIDER achieved 74% 2-y PFS in the dose-escalated arm, and this the best I have seen, so far.
pCR following trimodality treatment is a difficult endpoint and mainly has to do with the selection of patients. Up to 30% of patients post TUR-B (without ANY other treatment) will be pCR if you repeat the TUR-B 4 weeks later. Some trials have recruited mainly patients with early pT2 disease, others have recruited patients with more advanced disease.

Yes, one can advocate that EVP should be followed by CRT (if not cystectomy eligible), but we don't really know if that's a good idea, because the trials have not be run yet.
What if CRT will ruin all the effect of IO on the bladder & nodes by killing off all the lymphocytes?
We have seen that concurrent use of IO and CRT may be a bad idea or even detrimental, for example in head&neck cancer .
There is one Japanese trial testing RT after EVP, we will see how this works out.

In my opinion, EVP can be a substitute for direct CRT in cystectomy unfit/unwilling patients, esp. those who are not the optimal candidates for trimodality treatment (the ones with residual tumor following TUR-B, or cT3, or alot of Tis). Based on the response after 3-4 cycles of EVP, one can still choose what to do next.
Those patients with cCR after EVP can potentially by managed with observation / Pembro for a year. Those with Tis/T1-residual disease can be treated with 6x intravesical BCG + Pembro for a year. Those with residual muscle invasive disease clearly need more treatment, either cystectomy or CRT.
You don't need to decide what to do in the beginning, anymore.
You just give 3-4 cycles of EVP and reassess.

One trial is currently testing EVP vs. trimodal treatment: EV-309. Sadly, it's missing a third arm: EVP + TMT.

 

[medgator]

That’s a new one.

Urologists treat evidence as a minor inconvenience where I am.

How about upfront cryo and adt for Gleason 8 Pca?

Urorads actually would have solved all of these problems of inappropriate hifu, cryo abd RP but in its infinite wisdom ASTRO PAC opposed it like crazy and essentially implied it was shameful to go work for one of these setups