Questions discussed in this category
Can chemoradiation be curative without maximal debulking TURBT?
MiT subfamily translocations = TFE3, TFEB, TFC, or MiTF
Given long term data from Keynote 052 for pembrolizumab presented at ASCO 2021.
What factors impact your treatment decisions?
For cis-ineligible PD-...
Gleason 4+3=7 and PSA 4
When is the optimal time (if ever) for cytoreductive nephrectomy?
Does patient age effect your approach?
Would you consider RPLND for any patients in light of the phase II SEMS trial presented at the 2021 ASCO GU Ca...
Are there other adverse features aside from seminal vesicle invasion, positive margins, or extraprostatic extension that you consider?
Would you radiate? Surgery? Chemo? Follow with short interval scans?
How would size of adenopathy (e.g. <2cm vs larger) and time of recurrence (wi...
GS 4+4. PSA low (1-2). CT and bone scan negative for lymphadenopathy or metastatic disease. Prostate MRI pending.
Given antiangiogenic activity, is any TKI an option?
Any special precautions needed?
In this case, nivo/ipi discontinued for immune-related arthralgias requiring steroids and an anti-TNFa agent, now off all immunosuppression.
The site of oligometastatic disease was to a supra-clavicular node and was biopsy proven.
What other agents would have activity in a patient with NGS without actionable mutations?
What clinicopathological features would need to be present for you to recommend adjuvant chemotherapy? Would you treat pT3 disease? Any specific histo...
Does post docetaxel PSA influence your decision?
Specifically, would you offer salvage radiation to a patient who underwent a prostatectomy with PLND and had a post-op PSA of 12 with pathology reveal...
What line would you give pembrolizumab?
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?
There was an abstract in European J of Cancer (Srinivasan R, 2014:50: S6, P8) showing a good response rate with Bevacizumab and Erlotinib. Would you u...
Are MMR deficient tumors more resistant to cisplatin/carboplatin?
Is the short time to recurrence a reason to not consider definitive management with surgery/radiation?
Should systemic therapy be added if pursuing d...
How does dialysis affect PSA lab values?
Would you offer for T2N0 G3 resected disease with LVI?
Specifically, for cT2N0M0 small cell bladder cancer without response to neoadjuvant cisplatin and etoposide on imaging, would you proceed with cystect...
For patients who have progressed on first line checkpoint inhibitor (e.g. Nivo/Ipi) and second line TKI (e.g. Cabozantinib)
What systemic therapy options are available for ESRD patients?
Would you add abiraterone or enzalutamide?
What neoadjuvant or adjuvant therapy would you give?
Would you consider using them in patients with CHEK2 mutations?
A recent NCBD analysis (Rusthoven et al, JCO 2016) suggests that the addition of prostate RT significantly improves survival compared to ADT alon...
Ex: TKI alone, TKI + checkpoint inhibitor, checkpoint inhibitor alone, TKI + mTOR inhibitor. Please specify drug regimen, if applicable.
Would it change your decision if they had progressed on a first-line trial with cisplatin followed by pembrolizumab plus enfortumab vedotin maintenanc...
What clinical scenario(s) do you find results to be the most beneficial?
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?
If no testicular mass on exam or ultrasound - is there a role for orchiectomy? What chemotherapy regimen would you use and how many cycles?
Does the specimen (blood vs tissue) used to detect mutation affect your consideration?
For example, is there any data to suggest a benefit to starting with immunotherapy prior to TKI or the alternative?
Are there particular populations in whom you would add an AR targeted agent after docetaxel?
Assuming patient received appropriate local therapy for brain metastases, which agent would you use?
Are there any chemotherapy regimens that can be used in elderly patients with poor PS who are not candidate for BEP?
HERO study - https://clinicaltrials.gov/ct2/show/NCT03085095
i.e. Cisplatin + Etoposide
Some considerations:
-Cabozantinib (Based on CABOSUN trial, NCCN does not list this as a Category 1 recommendation)-Nivolumab + Ipilimumab (CheckMate...
Is there any specific precautions or concerns to consider with TKI initiation if the patient has vasogenic edema?
Would you do systemic treatment or observe?
(assuming that the patient is int-poor risk, has measurable disease outside of the CNS, warrants treatment with appropriate PS)
Given that ADT + abiraterone and ADT + docetaxel have not been directly compared.
Is there data to support proceeding directly to cystectomy?
What is the time window in which you would consider adding AR targeted therapy?
Is there a time frame in which you would NOT consider introducing sin...
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?
Is there an optimal strategy to minimize unnecesary steroid use?For example, pre-treatment dexamethasone or 3 day dexamethasone? Prednisone only conti...
If so, for how long would you treat?
Is there data and FDA approval for this indication?
What about for nodal failure after radiation?
How does your approach differ for patients with stage IIA versus IIB disease? Age?
https://meetinglibrary.asco.org/record/186872/abstract
How do you weigh the negative results from IMvigor 010 of adjuvant atezolizumab vs the results...
An ASCO 2020 poster from the German Testicular Cancer Study Group found that 37% of CSIS seminoma and nonseminoma were miscatagorized resulting in ina...
If offering neoadjuvant chemotherapy, which regimen would you use?
Should treatment be based on current histology (rhabdomyosarcoma) or origin (germ cell)?
Patient has MSKCC high risk disease. Immunosuppression is with mycophenolate mofetil and tacrolimus.
GI work up negative. NGS cancer type and isochromosome 12p ordered and pending. Pathology at RPLND was negative for cancer.
There are conflicting reports of increased incidence of bleomycin-induced lung toxicity with G-CSF.
Brain metastases have undergone resection, SBRT and WBRT
Would you forego neoadjuvant chemotherapy?
Are you using growth factor support differently?
Any changes to immunotherapy?
Other considerations?
Is this also a marker of TKI sensitivity?
Residual disease with bulky retroperitoneal masses also present on scans
Assuming patient is not a surgical candidate and wishes to pursue definitive radiotherapy, what duration of ADT would you give?
How would a much higher risk cancer affect decision making? How would you treat him?
Abstract 5014 at ASCO annual meeting 2019 showed superiority of PSMA-PET imaging over fluciclovine-PET imaging. Are you utilizing these speciali...
Are there any special considerations with the PNET?
In the SPARTAN trial, median PSA at study entry was ~ 7. Does the MFS benefit extend to patients with low PSA(< 2 or < 1)?
Does the extent of the surgery matter?
For instance, if the fluclicovine scan shows a few small avid nodes not only in the pelvis but extending to the paraaortic region, would you treat the...
NCCN include active surveillance as an option in specific circumstances based on Rini et al. (Lancet Oncology 2016) however this set is not well defin...
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?
Based on the RADICALS-RT trial presented at ESMO, can RT be omitted in post op prostate patients in favor of salvage RT? If not which group of patient...
Would you treat until progression or for a defined "adjuvant" course after nephrectomy?
i.e. gross disease on scans that is too diffuse to be removed completely and/or decreasing but not normal markers
Do you pursue close surveillance, s...
In this case, Gleason 5+5 in all cores, clinical T4.
Specifically, would you consider utilizing sodium thiosulfate in adults based on the pediatric data from Brock et al. NEJM 2018?
How do you assess risk of tumor lysis syndrome, and is hydration sufficient or should hypouricemic agents be used as well?
Given the national shortage of etoposide starting in February 2018?
What would be a safe dose for ifosfamide and how would you time with HD? Alternatively, would you recommend a different regimen? What about using neoa...
How long would you continue androgen deprivation after radiation?
UpToDate indicates that VIP is an alternative to BEP for men who are not candidates for bleomycin, and that one criteria for not being such a candidat...
Patient has small cell carcinoma of the bladder with extensive hepatic metastases. Would you extrapolate the approach from IMpower133?
Retrospective data show very low response rate of immunotherapy in FGFR mutated patients.
Should cystectomy remain standard of care?
(Recently debated in JAMA Oncology:
http://jamanetwork.com/journals/jamaoncology/article-abstract/2520055...
In a patient with a prior response to ADT and progression on taxane and platinum chemotherapy, would you consider AR directed therapy?
Would you give chemotherapy concurrently with radiation? Would you change your radiation dose?
Does the STAMPEDE trial, showing a survival benefit with the addition of docetaxel to standard treatment, change the standard of care for high risk, n...
Would you offer definitive management with radiation and ADT? Or systemic therapy alone such as with ADT+abiraterone?
Mixed opinions about efficacy of IO therapy in this subtype.
ENZAMET and TITAN trials published at ASCO 2019 show benefit to both 2nd generation AR antagonists when compared to placebo but wondering how this wil...
What factors do you consider to aid in this decision making? The TIGER trial is a prospective randomized trial comparing these approaches.
Is there any data as to whether TKI or immunotherapy is more effective in this population?
Are there any patient and/or pathologic features that would lend you to considering IL-2 over other approved I/O or TKI therapies?
I have seen the question regarding treatment of non-clear cell RCC in general: https://www.themednet.org/question/3934. Is there any data or experienc...
Arterial events have clear instructions to permanently discontinue on the FDA label. Especially in HCC without many other treatment options, giv...
In light of the data from ERA223 showing increased deaths and fractures with the combination of radium-223 and abiraterone compared to abiraterone alo...
Assuming there was an initial period of response to the mCRPC treatment.
Would you add atezolizumab to carboplatin + etoposide for small cell/neuroendocrine prostate cancer?
Treatment for small cell/neuroendocrine prostate is extrapolated from data on small cell lung cancer. It now appears that Carboplatin + Etoposide + At...
Are you directed by symptoms, PSA changes or do you have a standard schedule regardless of those factors?
Late relapse, previously treated with BEP 30 years ago.
Would you consider treatment based upon imaging alone or would you wait for tissue confirmation of metastatic disease?
NCCN guidelines suggest systemic therapy only or concurrent chemoradiotherapy. What is your approach?
Abstract LBA5_PR ‘Radiotherapy (RT) to the primary tumour for men with newly-diagnosed metastatic prostate cancer (PCA): survival results from S...
Prospective International Randomized Phase II Study of Low-Dose Abiteraterone with Food versus Standard Dose Abiraterone In Castration-Resistant Prost...
In a patient s/p orchiectomy and with pelvic lymphadenopathy, would you consider lymph node biopsy to confirm involvement by non-seminomatous germ cel...
Most of the studies have excluded non clear cell histologies. If you use a similar approach to clear cell, have you seen similar responses?
For which patients would you consider addition of apalutamide or enzalutamide? How do you decide between the 2 drugs?
The recent SPARTAN trial showed a remarkable improvement in metastasis free survival and many other secondary endpoints except the lack of significant...
NCCN recommends to change therapy or maintain current therapy in this setting without further clarification. What thresholds would cause a change in t...
Is there any role for orchiectomy in this setting?
What are the special considerations in the non-metastatic setting vs metastatic setting?
Testicular ultrasound, CT, and tumor markers are without abnormalities outside of the mass.
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?
If yes, what factors push you to test for AR-V7 or would you test all patients in this clinical scenario?
Would you initiate abiraterone or enzalutamide for the rising PSA or wait until the patient is symptomatic or has a new site of metastasis?
Current NCCN guidelines seem to support a variety of approaches.
The patient is cisplatin ineligible due to renal dysfunction.
Pt previously treated with radical prostatectomy and adjuvant radiotherapy.
If recommending therapy, what is the role of concurrent abiraterone + AD...
Based on new FDA approval of nivolumab plus ipilimumab in the first-line setting for intermediate- and poor-risk disease, would you give the combinati...
Could observation and serial cystoscopy be a reasonable option or is surgery necessary? If recommending surgery, can a procedure less than a nephroure...
Data reported by Motzer et al Lancet 2015 demonstrated a statistically superior PFS benefit of lenvatinib monotherapy over everolimus alone. In partic...
Would you recommend radiation and/or systemic therapy? If you would irradiate, what would your fields/volumes look like?
Recent evidence has been mixed, with no DFS or OS benefit in 1 trial (ASSURE, Haas et al, Lancet 2016) and DFS benefit in another (S-TRAC, Ravaud et a...
Is there a treatment that you prefer for such patients?
Given the apparently stronger results from KEYNOTE 052 (pembrolizumab) compared to IMvigor 211 (atezolizumab), would you consider pembrolizumab for pa...
The current treatment for bladder adenoCA is surgery. However in non-surgical candidates, RT is an option. Would you consider adding chemo ? Also woul...
If so, what chemotherapy regimen would you use? If not, what management options would you generally recommend?
Alternatively, would a biopsy of a metastatic bone lesion be preferred in a patient who has already progressed on chemo and hormonal therapy?
Given the FDA breakthrough therapy designation for olaparib in BRCA1/2 and ATM mutated mCRPC, when do you sequence mCRPC? Do you have a preferred...
Based on 2-3% MSH2 mutation and 1% MLH1 mutation rates in metastatic disease regardless of castration sensitivity, should we be looking for this earli...
Would you offer definitive radiation/chemoradiation if he is refusing cystectomy?
If current systemic treatment is otherwise controlling the disease and is well-tolerated, is there value to locally aggressive therapy in an attempt t...
In patients with new bone pain and without any evidence of bone metastases receiving GnRH agonists, how do you manage pain symptoms?
Pending head-to-head comparisons, do you believe there are any subgroups who might benefit more from one or the other?
Are the results of the STAMPEDE trial presented at ASCO 2017 practice changing?
Given the non-specific nature of AFP and its elevation in various benign conditions, is there an AFP cutoff level or change over time for which you wo...
Which patients do you consider to be chemotherapy-ineligible for the sake of this treatment decision? How strong does the contraindication need to be?
What clinical considerations factor into your decision to choose leuprolide vs goserelin vs triptorelin vs degarelix, etc?
NCCN guidelines offer suggested schedules for interval imaging and laboratory studies, but also make it clear that the quality of evidence for these r...
What determines which you select first? How do concerns about cross-resistance factor in after progression on one of these agents?
To what extent do you worry about overlapping myelosuppression? Is there any advantage to overlapping therapy?
Is there a role for salvage LN dissection or salvage RT to the node? And is there a role for systemic therapy (ADT or chemotherapy) in addition? If yo...
Two retrospective studies from Stanford showed that patients who received ADT had an increased risk of dementia and Alzheimer's. Is this finding ...
Do you use a PSA threshold, PSA doubling time, or only evidence of metastatic disease to trigger ADT? For those without rapid doubling time, do you ev...
And how should we compare checkpoint inhibitors? Given the FDA approval of atezolizumab and nivolumab as second-line agents for metastatic urothe...
The Intergroup 0162 trial did not demonstrate noninferiority, although OS difference only 5.1 vs. 5.8 yrs. Would pattern of spread affect your d...
When would you use surveillance versus repeat excision or adjuvant systemic or local therapy?
The CABOSUN trial showed a benefit in PFS and ORR, with unchanged OS, over sunitinib.
In the setting of recent craniotomy and a plan for SRS to the surgical cavity, which systemic therapy would you choose and when would you&nb...
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 ...
How do you approach management of locally-advanced, unresectable, but non-metastatic bladder cancer?
When do you offer trimodality bladder-sparing approaches? Is there any role for starting standard neoadjuvant therapy in an attempt to convert to rese...
Or in patients with metastatic disease on ADT who have not had primary therapy? In what situations do you consider palliative prostatectomy?
After confirming castration levels of testosterone, is the next best step to add docetaxel (as in CHAARTED and STAMPEDE, although not explicitly for G...
When are you concerned for a false positive? FDA guidelines include a suggestion to try another assay in case heterophile antibodies are causing a fal...
Radium-223 has an overall survival benefit and lower hematologic toxicity, but at a significantly increased cost. Does the cost-effectiveness fa...
If so, at what point? McDermott et al. demonstrated some lasting responses after discontinuation of therapy (JCO 2015), but these responses are s...
How might a recent (within 6 months) myocardial infarction affect your recommendations?
For patients who developed oligometastases while off systemic treatment, do you start systemic therapy following local therapy or return to active sur...
Are there circumstances when you would choose IL-2 over checkpoint inhibitor trials or TKIs for fit patients? How should IL-2 be sequenced with these ...
In which circumstances should high-dose chemotherapy with autologous stem cell transplant be considered, versus second-line chemotherapy regimens or c...
Based on the abstract from IMvigor 210 presented at ASCO this year, are you offering atezo to patients who otherwise may not tolerate platinum-based c...
Based on a recent single-arm phase II trial, is there a role for paclitaxel, ifosfamide, and cisplatin (TIP) as a first-line regimen instead of BEP?
Do other factors (i.e. Gleason score, pretreatment PSA, or pT stage) affect your decision?
Given recent advancements in the understanding of biological differences in prostate cancer patients of African vs. other ancestry, does your manageme...
How has CARMENA changed your practice?
For patients who remain fit and interested in treatment, but for whom a clinical trial is not an option, what systemic therapy do you reach for in thi...
Only the mCRPC population was included in the Fizazi et al. study, but the FDA approval is for prevention of skeletal related events from any solid tu...
Are there specific subsets for whom these results should change management?
If so, how do you sequence this with other therapies? In addition, in the absence of an effect on radiographic PFS or serum PSA, how do you asse...
In situations where there is a significant risk of either local or nodal persistence/recurrence post prostatectomy with a rising PSA, or nodal involve...
In the IMvigor 210 trial, increased PD-L1 expression in patients’ tumors was associated with response to atezolizumab, but some patients whose t...
A recent systematic review suggested that disease progression owing to a testosterone "flare" may not be a real phenomenon: http://www.ncbi.nlm.nih.go...
Since the benefit of neoadjuvant chemotherapy is well-defined in muscle-invasive bladder cancer, is it reasonable to consider this in upper-tract tumo...
The role of adjuvant docetaxel with ADT following RT for high risk disease has been previously elucidated by RTOG 0521. Following prostatectomy,...
At the ASCO 2016 annual meeting, results of the PRINCE trial were reported. A strategy of intermittent docetaxel was found to be non-inferior to conti...
In a patient with node positive disease, treated definitively with radiation, should continuous or intermittent ADT be administered? If a patien...
Typically radium-223 is reserved for men with symptomatic bone disease after failure of multiple other therapies. Is there a population of men w...
Is any amount of teratoma or PNET an indication for surgery?
Do you favor a short palliative regimen, or a full course definitive treatment to 64.8Gy? How does your management change if the patient has a good pe...
What factors should be considered with offering SBRT to oligometastatic bone disease in prostate cancer patients? Should this been done off of a proto...
Assuming a patient who could tolerate either, which is preferred? Does this depend on the choice for concurrent chemotherapy (5FU+mitomycin vs ci...
Papers discussed in this category
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Clinical cancer research : an official journal of the American Association for Cancer Research, 2015-09-01
Eur Urol, 2015 Jul 16
BJU Int, 2009 Feb
European urology, 2014-06
The New England journal of medicine, 2013-07-18
Lancet, 2016 Mar 19
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2019-05-10
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-01-20
The New England journal of medicine, 2004-10-07
JAMA oncology, 2016-11-01
J. Nucl. Med., 2015 Jun 25
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2008-04-01
Lancet Oncol., 2010-02-01
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2006-03-20
The Journal of urology, 2005-08
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2002-08-01
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2011-06-20
The Journal of urology, 2002-09
Clinical cancer research : an official journal of the American Association for Cancer Research, 2009-01-15
Nature, 2005-12-08
J Clin Oncol, 1999 Jul
Lancet, 2015 Jan 3
The New England journal of medicine, 2001-12-06
Lancet, 2001-09-22
Breast Cancer Res. Treat., 2010-02-01
The Journal of urology, 1982-06
Cancer research, 2000-04-15
J. Clin. Oncol., 2009-04-01
Oncol. Rep., 2015-12-01
Nat Commun, 2015-04-01
PLoS ONE, 2016-01-01
J. Urol., 2002-04-01
European urology, 2018-02
Lancet, 2018 Oct 18
Indian J Urol,
The Lancet. Oncology, 2006-06
Lancet (London, England), 2016-05-07
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-06-20
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-02-20
JAMA oncology, 2016-04
JAMA oncology, 2017-01-01
JAMA, 2009-08-26
European urology, 2015-05
JAMA, 2008-01-23
Clinical cancer research : an official journal of the American Association for Cancer Research, 2015-02-01
Journal for immunotherapy of cancer, 2015
Cancer immunology, immunotherapy : CII, 2016-08
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 1995-03
The cancer journal from Scientific American, 2000-02
Cancer immunology, immunotherapy : CII, 2016-12
Urologic oncology, 2015-11
Lancet (London, England), 2016-05-14
The New England journal of medicine, 2016-12-08
JAMA oncology, 2017-09-01
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017-12-10
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2015-06-20
Canadian Agency for Drugs and Technologies in Health, 2016-10-31
Medicine (Baltimore),
Future Oncol, 2015 Oct 05
JCO Precision Oncology, 2017 May 31
The New England journal of medicine, 2016-08-04
Prostate cancer and prostatic diseases, 2014-09
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017-02-20
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2016-08-20
The New England journal of medicine, 2017-03-16
The New England journal of medicine, 2018-04-12
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European urology, 2012-04
European urology, 2014-07
N. Engl. J. Med., 2012-04-19
J. Urol., 2007-09-01
J. Clin. Oncol., 2006-05-20
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2017-07-10
The New England journal of medicine, 2015-08-20
Lancet (London, England), 2017-01-07
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2018-06-10
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Nature, 2013-07-11
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Clinical genitourinary cancer, 2017-12
Prostate Int,
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, 2018-05-10
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AJR. American journal of roentgenology, 2019-10
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Annals of oncology : official journal of the European Society for Medical Oncology, 2010-04
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The New England journal of medicine, 2003-08-28
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BJU international, 2011-09
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Cancer,
Nature genetics, 2016-04
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Urology, 2001-08
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Lancet Oncol., 2016-06-01
JAMA Oncol, 2020 Mar 26
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Anticancer Drugs,
Cancer, 2010-11-15
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Clinical genitourinary cancer, 2018-12
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Clinical genitourinary cancer, 2017-06
The Journal of urology, 2014-02
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