Bladder Cancer   

NCCN guidelines suggest systemic therapy only or concurrent chemoradiotherapy. What is your approach?

What dose and fields of treatment would you recommend? 

GETUG-AFU V05 VESPER TrialDid the ASCO 2023 overall survival data change your practice?

How do you decide between ureteral stent and percutaneous nephrostomy for decompression?

Since the benefit of neoadjuvant chemotherapy is well-defined in muscle-invasive bladder cancer, is it reasonable to consider this in upper-tract tumo...

Had mild baseline tinnitus, now with significant worsening, and decreased hearing. 

Surgical data suggests improved survival with pelvic lymphadenectomy and is recommended by NCCN guidelines, however the same is not seen with RT data....

The NCCN lists concurrent chemoradiotherapy as a primary treatment option in these patients. If so, what total dose do you deliver to involved ly...

Would treatment be palliative (i.e. for ureteral obstruction) or definitive? Is there a role for chemotherapy or hypofractionation/SBRT?

Would a PET avid pelvic lymph node without distant metastatic disease change your management?

This would be for the "locally advanced unresectable" indication. Consider an older patient who is not eligible for NAC nor TMT due to nodal disease a...

Does obstructive hydronephrosis allow for clinical upstaging to stages 2-3? 

Has this recent retrospective analysis published in Lancet Oncology changed your practice?

Assuming no symptoms of TB, should patients be treated for latent TB prior to starting TNF inhibitors or other immunosuppressive agents?

Will you await manuscript publication and formal regulatory approval prior to routinely instituting this treatment?

Galsky criteria are for metastatic disease, can they be relaxed in localized MIBC setting given curative intent of therapy? 

Can chemoradiation be curative without maximal debulking TURBT?

Are there concerns for under-staging with bladder cancer in diverticulum?

If so, which checkpoint inhibitor would you use?

What patient factors do you consider to decide between 55 Gy/20 fx and 64 Gy/32 fx with or without nodal irradiation? What if your patient is younger ...

If the patient received <2 months of immunotherapy, would you continue immunotherapy alone or transition to enfortumab monotherapy or EV+Pembro?

Are you waiting for BCG to become available or are you using other bridging therapies such as pembrolizumab?

How do you decide between downstaging chemotherapy or upfront concurrent chemoradiotherapy? Both are listed as NCCN options. 

General recommendations on dose and management presuming unresectable. 

If the patient has had prior prostate radiation and is not a surgical candidate, would you treat with systemic therapy alone? What is the natural his...

What is the potential risk of immunotherapy toxicity in combining palliative RT in a patient already on immunotherapy?

Confirmed no urothelial carcinoma and muscle in specimen without involvement. 

Is there concern for increased toxicity from erdafitinib following avelumab similar to osimertinib toxicity following pembrolizumab in NSCLC? Does FGF...

If so, do you use it for all patients or only cisplatin doses >= 70 mg/m2? What dose of mannitol do you use?

Does specific mixed histology variant change recommendation?

If you do recommend adjuvant therapy, what regimen would you use?

NCCN states to consider adjuvant chemotherapy similar to muscle invasive bladder cancer in this scenario, but one would avert adjuvant chemotherapy in...

Would T or N group change your recommendation?

Does this raise concerns about the efficacy of adjuvant immune checkpoint inhibition? Are any preliminary results from AMBASSADOR (adjuvant pembrolizu...

Weekly (20 mg/m2 D1, D2) and q 3 wks (70 mg/m2 x 3c or 100 mg/m2 x 3c) regimens have all been listed as acceptable.  For reference, RTOG 97&...

The forest plot from CheckMate 274 did not show a benefit for such patients? How would you select between adjuvant chemotherapy and adjuvant nivoluma...

Specifically, for high grade T1 bladder cancer, is there evidence that definitive radiation yields similar control rates compared to cystectomy?

Do you think adjuvant nivolumab should be the new standard of care based on current CM274 DFS data? If OS turns out to be no different, will you still...

How does prior chemotherapy, site of disease, and pathological staging inform your decision? How about molecular markers (PD-L1, ctDNA)?

Is a 3 month delay too long in someone who had postoperative complications?

Does PDL1 status impact your decision?

NGS of TURBT specimen had high TMB (18 Muts/Mb).

Would you do consolidation radiation or active surveillance? Would presence of variant histology change your recommendation?

If not carboplatin, would you recommend nivolumab instead?

If any clinical benefit (ie. CR, PR or SD) would you consider switch maintenance avelumab, surveillance until progression, or an alternate regimen?

Molecular profiling revealed no targetable alterations, however tumor mutational burden was >10 mut/Mb.

The recommended concurrent chemotherapy regimens (cisplatin/paclitaxel and cisplatin/FU) in NCCN are based on BID fractionation of radiation as in RTO...

How would non-regional adenopathy change management? What about poor surgical candidacy?

Would radical prostatectomy and PLND suffice or would a cystectomy be warranted (even in the absence of bladder involvement) as well? 

If no direct invasion into prostate from bladder or urethra, is there any role for systemic therapy?

Any role for surgical extirpation vs systemic treatment?

Patient has not had any prior systemic treatment and is cisplatin-eligible.

Given long term data from Keynote 052 for pembrolizumab presented at ASCO 2021. What factors impact your treatment decisions? For cis-ineligible PD-...

What would your treatment approach be- surgery or chemoRT? What is your preferred chemo regimen? Is there a % threshold other than 100% (e.g. 95%) th...

Assuming no actionable mutations?

Specifically, for cT2N0M0 small cell bladder cancer without response to neoadjuvant cisplatin and etoposide on imaging, would you proceed with cystect...

What neoadjuvant or adjuvant therapy would you give?

Would it change your decision if they had progressed on a first-line trial with cisplatin followed by pembrolizumab plus enfortumab vedotin maintenanc...

Is there a role for neoadjuvant cisplatin-based chemotherapy? Do patients with sarcomatoid histology respond to checkpoint inhibitors?

No actionable mutation on NGS testing. What approved therapy do you prefer? Are there specific investigational agents currently in clinical trial...

Any role of neoadjuvant chemotherapy?

i.e.  Cisplatin + Etoposide

Is there data to support proceeding directly to cystectomy?

If so, what regimen would you use? Would a carboplatin-based regimen be acceptable or only cisplatin?

Do you prefer surgery vs radiation? For surgical patients, do you offer neoadjuvant chemotherapy? If so what regimen? 

If so, for how long would you treat?

https://meetinglibrary.asco.org/record/186872/abstract How do you weigh the negative results from IMvigor 010 of adjuvant atezolizumab vs the results...

If offering neoadjuvant chemotherapy, which regimen would you use?

Would you forego neoadjuvant chemotherapy? Are you using growth factor support differently? Any changes to immunotherapy? Other considerations?

Any role to switch to MVAC?

Would you treat with chemoimmunotherapy based on IMvigor130 data presented at ESMO Congress 2019?

e.g. lymph node metastasis, presence of tumor involving the peritoneal surfaces and/or the abdominal wall. If so, which regimen would you offer?

Patient has small cell carcinoma of the bladder with extensive hepatic metastases. Would you extrapolate the approach from IMpower133?

There are now five PD-1/PDL-1 inhibitors approved for metastatic bladder CA, one (Atezolizumab) as first-line therapy in cisplatin-ineligible patients...

What systemic therapy do you use? Do you incorporate any multi-modality therapies?

Current NCCN guidelines seem to support a variety of approaches.

Would you recommend radiation and/or systemic therapy? If you would irradiate, what would your fields/volumes look like? 

The current treatment for bladder adenoCA is surgery. However in non-surgical candidates, RT is an option. Would you consider adding chemo ? Also woul...

Would you offer it for positive margins? NCCN says to consider adjuvant radiation for pT3-T4 or pN0-2. Is there sufficient evidence for adjuvant radia...

If so, is there a role for IMRT?  I was taught to use the RTOG style ports with whole pelvis 4 field box and then boost field to entire bladder ...

For a patient with a history of non-muscle invasive disease in the bladder, presenting with a prostatic urethra only recurrence, do you approach this ...

In the IMvigor 210 trial, increased PD-L1 expression in patients’ tumors was associated with response to atezolizumab, but some patients whose t...

I've heard justification for treating the whole bladder to 60-64 Gy based on the UK MRC study (James et al. NEJM 2012 and Huddart et al. IJROBP 2013) ...

In this case, the patient is currently on maintenance BCG.

Realistically, there will always be some (hopefully small) inconsistency with bladder filling, and thus some small bowel could easily receive &ge...

Assuming a patient who could tolerate either, which is preferred? Does this depend on the choice for concurrent chemotherapy (5FU+mitomycin vs ci...

Following a mini-pelvis field?

In the definitive setting, and would that change if cystecomy was planned if there was a complete response after CRT?  (similar to TCC paradigm).