The Role of Maximal TURBT in Muscle-Invasive Bladder Cancer: Balancing Benefits in Bladder Preservation and Beyond

Radical cystectomy with lymph node dissection and urinary diversion is the gold-standard treatment for non-metastatic muscle-invasive bladder cancer (MIBC). However, in patients who refuse cystectomy, or in whom cystectomy carries a high risk, bladder-preserving therapies remain potential options. Bladder preservation therapies can include maximal debulking transurethral resection of bladder tumor (TURBT), concurrent chemoradiation therapy, followed by cystoscopy to assess response. At this time, maximal TURBT is recommended for patients prior to the initiation of chemoradiation therapy or in patients with residual bladder tumors after the completion of chemoradiation therapy. That being said, TURBT carries significant risks such as bladder perforation, bleeding, and infection, ultimately risking delayed systemic treatment. Hence, understanding its role within trimodal therapy is crucial to avoid undue suffering in patients. Herein, we review the current literature on the impact of debulking TURBT in non-metastatic MIBC.

Comprehensive analysis of targetable mutations and tumor microenvironment in urachal cancer

Urachal cancer, a rare malignancy, generally presents in the clinical setting with advanced stages of disease. Systemic treatment with chemotherapy is generally utilized in this setting. However, there remains a paucity of data on the effectiveness of immune checkpoint inhibitors or targeted therapies for urachal cancer. We analyzed the genomic profile of urachal cancer in order to identify potentially targetable mutations and evaluate the tumor microenvironment. 42 urachal samples were retrospectively analyzed. Our results showed that TP53, GNAS and KRAS mutations were common in urachal cancer with increased prevalence of TP53 mutation in urachal cohorts without MAPK-alterations. The tumor microenvironment demonstrated increased NK cells in MAPK-altered urachal cancer. Finally, we show that urachal cancer shares genomic and transcriptomic similarity with colorectal cancer compared to bladder cancer. This study provides new insights into the molecular profiles of urachal tumor samples and possibility of association with colorectal cancer that might guide future clinical trial design.

Best Patient Care Practices for Administering PSMA-Targeted Radiopharmaceutical Therapy

Optimal patient management protocols for metastatic castration-resistant prostate cancer (mCRPC) are poorly defined and even further complexified with new therapy approvals, such as radiopharmaceuticals. The prostate-specific membrane antigen (PSMA)-targeted agent 177Lu vipivotide tetraxetan ([177Lu]Lu-PSMA-617), approved after the phase III VISION study, presents physicians with additional aspects of patient management, including specific adverse event (AE) monitoring and management, as well as radiation safety. Drawing on our experience as VISION study investigators, here we provide guidance on best practices for delivering PSMA-targeted radiopharmaceutical therapy (RPT) to patients with mCRPC. After a comprehensive review of published evidence and guidelines on RPT management in prostate cancer, we identified educational gaps in managing the radiation safety and AEs associated with [177Lu]Lu-PSMA-617. Our results showed that providing sufficient education on AEs (e.g., fatigue and dry mouth) and radiation safety principles is key to effective delivery and management of patient expectations. Patient counseling by health care professionals, across disciplines, is a cornerstone of optimal patient management during PSMA-targeted RPT. Multidisciplinary collaboration is crucial, and physicians must adhere to radiation safety protocols and counsel patients on radiation safety considerations. Treatment with [177Lu]Lu-PSMA-617 is generally well tolerated; however, additional interventions may be required, such as dosing modification, medications, or transfusions. Urinary incontinence can be challenging in the context of radiation safety. Multidisciplinary collaboration between medical oncologists and nuclear medicine teams ensures that patients are monitored and managed safely and efficiently. In clinical practice, the benefit-to-risk ratio should always be evaluated on a case-by-case basis.

Pairing the Right Individual with the Right Regimen: Patient Selection Criteria in the Treatment of Advanced Urothelial Carcinoma

Enfortumab vedotin plus pembrolizumab is a very effective regimen in the treatment of advanced urothelial carcinoma but is difficult to tolerate. We discuss the rationale for establishing patient selection criteria for this combination, taking into consideration the potential for life-altering side effects, limited real-world experience with the regimen among oncologists, patient preferences in balancing treatment effectiveness against toxicity, and the precedent in establishing eligibility criteria for platinum-based chemotherapy.

Treatment approaches for urachal cancer: Use of immunotherapy and targeted therapies

Urachal cancer is a rare genitourinary malignancy that arises from the embryologic remnant of the urachus. The malignancy is considered to be aggressive, with no clear consensus on appropriate management for advanced disease. Although traditionally considered to be related to bladder cancer given its embryologic origin, several next generation sequencing studies have revealed the genomic profile of this genitourinary malignancy most closely resembles colorectal cancer. Moreover, these studies have identified potentially actionable mutations including EGFR, KRAS and MET. In addition, recent data suggests that immunotherapy may benefit some patients with advanced urachal cancer. Nonetheless, continued research is warranted to better understand how to treat this rare genitourinary cancer.

The Genitourinary Medical Oncology Workforce in the United States

OBJECTIVE

To characterize the genitourinary medical oncology workforce in the United States.

METHODS

Utilizing the top cancer hospitals as ranked by US News & World Reports, genitourinary medical oncologists in each state of the United States were identified. Data including gender, race/ethnicity, site of medical education, and site of clinical practice were collected.

RESULTS

A total of 451 genitourinary medical oncologists are involved in clinical care in the United States. Of these medical oncologists, 399 (88.5%) practice in academic settings while 52 (11.5%) practice in community-based settings. 327 (72.5%) of genitourinary medical oncologists are male, while 124 (27.5%) are female. 17 (3.8%) genitourinary medical oncologists are from under-represented minority groups in medicine (Black, Hispanic, or Native American). 321 (71.2%) genitourinary medical oncologists received training at medical schools in the US, while 130 (28.8%) trained at medical schools abroad. The Northeast US has the most genitourinary medical oncologists with 150, followed by the South with 129, the West with 97, and the Midwest with 75. Of note, seven states, including Alaska, Delaware, Idaho, Maine, North Dakota, South Dakota, and Wyoming, have no identified genitourinary medical oncologist.

CONCLUSION

Disparities based off gender, race/ethnicity, and geographic location of practice exist in the genitourinary medical oncology workforce in the United States.

A remnant never forgotten: the utility of circulating tumor DNA in treatment guidance of urachal cancer

Urachal cancer is a rare malignancy of the urachus that is treated with surgical resection if localized and systemic chemotherapy for metastatic disease. Circulating tumor DNA (ctDNA) is a single-stranded or double-stranded DNA released by tumor cells into the blood and harbored the mutations of the original tumor, shedding new light on molecular diagnosis and monitoring of cancer. We report a case of resected localized urachal cancer with clear surgical margins and negative lymph node dissection but elevated ctDNA that progressed to metastatic disease. We also highlight the possibility of using ctDNA levels to assist in adjuvant therapy.

Supplement Use and Increased Risks of Cancer: Unveiling the Other Side of the Coin

There is a rising trend in the consumption of dietary supplements, especially among adults, with the purpose of improving health. While marketing campaigns tout the potential health benefits of using dietary supplements, it is critical to evaluate the potential harmful effects associated with these supplements as well. The majority of the scarce research on the potential harmful effects of vitamins focuses on the acute or chronic toxicities associated with the use of dietary supplements. Quality research is still required to further investigate the risks of long-term use of dietary supplements, especially the risk of developing cancers. The present review concentrates on studies that have investigated the association between the risk of developing cancers and associated mortality with the risk of dietary supplements. Such an association has been reported for several vitamins, minerals, and other dietary supplements. Even though several of these studies come with their own shortcomings and critics, they must draw attention to further investigate long-term adverse effects of dietary supplements and advise consumers and healthcare providers to ponder the extensive use of dietary supplements.

Implications and Lessons from the Withdrawal of Sacituzumab Govitecan for Treating Advanced Urothelial Carcinoma

The recent withdrawal of sacituzumab govitecan for advanced urothelial carcinoma has revealed several implications, including concerns over a lack of remaining effective treatment options, reimbursement, supportive care measures (such as granulocyte-colony stimulating factor), dose reductions, and inconsistencies with related historical regulatory decisions.

The Role of Ayurveda in Prostate Cancer Management

Ayurveda is commonly utilized in the treatment of medical ailments but has yet to gain traction in incorporation into allopathic medicine. Prostate cancer is the most common cancer among men and presents a significant public health burden across the globe. Despite advancements in the management of advanced prostate cancer including androgen deprivation therapy and novel hormonal therapies, men may eventually develop resistance to hormonal therapy. As such, there is an urgent need for novel therapeutic options in treating this malignancy. This review examines the pre-clinical evidence for Ayurveda medicinal plants such as Withania somnifera, Glycyrrhiza spp, Momordica spp, Boswellia, and Bacopa monnieri and their potential application in managing prostate cancer. Several in-vitro and pre-clinical studies suggest potentials for these plants or their derivatives in preventing or treating prostate cancers. Despite strong evidence of efficacy of these plants to potentially improve the outcome of prostate cancer, clinical trials are required to evaluate which plants may be most efficacious and to determine effective dosing strategies, as well as the use of ayurvedic plants as standalone therapies or in combination with conventional prostate cancer treatments.

Safety and efficacy of first-line nivolumab plus ipilimumab alternating with nivolumab monotherapy in patients with advanced renal cell carcinoma: the non-randomised, open-label, phase IIIb/IV CheckMate 920 trial

OBJECTIVES

The non-randomised, open-label, phase IIIb/IV multicohort CheckMate 920 trial explored the safety and efficacy with a less frequent, but continual nivolumab plus ipilimumab (NIVO+IPI) dosing regimen (cohort 1) to determine whether this modification could potentially retain efficacy benefits while improving on the manageable safety profile previously observed with this combination in patients with advanced renal cell carcinoma (aRCC).

SETTING

Patients were enrolled from 48 largely community-based sites in the USA.

PARTICIPANTS

106 patients with previously untreated, predominantly clear cell aRCC received treatment.

INTERVENTIONS

Patients received NIVO 6 mg/kg plus IPI 1 mg/kg on day 1 of the first week of each 8-week cycle; the combination alternated with NIVO 480 mg monotherapy on day 1 of the fifth week of each 8-week cycle. Treatment continued until disease progression, unacceptable toxicity, withdrawal of consent or study end. The maximum treatment duration was 2 years. The primary endpoint was the incidence of high-grade (grade 3/4 and grade 5) immune-mediated adverse events (IMAEs) within 100 days of the last dose. Select secondary endpoints included time to onset and resolution of high-grade IMAEs, progression-free survival (PFS) and objective response rate (ORR). The incidence of treatment-related adverse events and the overall survival (OS) were the exploratory endpoints.

RESULTS

The most common grade 3/4 IMAEs were diarrhoea/colitis (7.5%) and rash (6.6%) and no grade 5 IMAEs occurred, with a minimum follow-up of 28.5 months. The median PFS was 4.8 (95% CI 3.0 to 8.3) months, the ORR in evaluable patients (n=96) was 34.4% (95% CI 25.0 to 44.8), and the median OS was not reached (95% CI 24.8 months to not estimable).

CONCLUSIONS

While no new safety signals were reported with less frequent, but continual NIVO+IPI dosing in CheckMate 920, the modified regimen was not associated with clinical benefits relative to the approved NIVO+IPI dose. These results support the continued use of the currently approved NIVO+IPI combination dosing schedule for patients with aRCC.

TRIAL REGISTRATION NUMBER

NCT02982954.

A comparative study of spinal cord compression management in metastatic prostate cancer: Teaching versus non-teaching hospitals in the United States

BACKGROUND

Spinal cord compression (SCC) in metastatic prostate cancer (MPC) is a critical complication and multiple factors influence the optimal therapeutic strategy. We investigated the differences in practice patterns between teaching hospitals (TH) and non-teaching hospitals (NTH) across the United States.

METHOD

Using the National Inpatient Sample Database (NIS), we performed a retrospective study on hospitalizations with MPC and SCC between 2016 and 2020 in US. We compared demographic factors, comorbidities, treatment modalities, duration of hospitalization, financial expenditures, and mortality between TH and NTH. We also examined the patients' characteristics and outcomes in TH and NTH based on their chosen therapeutic strategy.

RESULTS

We identified 11,380 admissions with metastatic prostate cancer and SCC; 9610 in TH and 1770 in NTH. The median cost of hospitalization was $21,922 in TH and $15,141 in NTH. Although the median age and Charlson comorbidity score did not differ between two groups, patients in TH were more likely to receive intervention (radiation or surgery) compared to NTH (Surgery: 28.2% in TH vs. 23.0% in NTH & Radiation: 12.1% in TH vs. 8.2% in NTH). Mortality was lower in TH than NTH (4.5% vs. 7.9%). In both TH and NTH, a higher proportion of patients with private insurance underwent surgery (TH: Surgery 25.1% vs. Radiation 18.8% & NTH: Surgery 27.0% vs. 6.9%). Black patients were more likely to receive radiation than surgery in TH (34.2% vs. 26.8%).

CONCLUSION

This study showed a greater percentage of patients underwent surgical intervention at TH compared to NTH. Additionally, the type of insurance and racial background were associated with distinctive treatment approaches.