Questions discussed in this category
Does your institution prefer use of temporary placement each cycle of a PICC line for 5 days outpatient or long-dwell IV? Do your patients require ser...
If CNS lesions were managed with surgery/radiation, is systemic therapy also warranted? If so, would you preferentially recommend 2nd line high dose c...
How do you generally approach BPH therapies after EBRT?
If ADT acts as a systemic treatment, we would have expected to see a benefit with an RP just like with radiation. Yet, this is not the case. What are ...
Are there any subgroups which can predict specific benefit (or lack thereof) such as patients with residual disease or PD-L1 overexpression?
What is the rationale for the recent change in the NCCN criteria for very high risk prostate cancer?
T3b and number of positive cores with GG4 disease are no longer criteria used to qualify patients for intensified hormone blockade, what rationale wen...
This patient's PSA rose from 0.2 to 2.0 at 3 months post-SBRT without PSMA avid lesions. How would you manage this: intensify treatment (such as with ...
Were you using gem/cis or ddMVAC more routinely prior to NIAGARA?
For example, if a patient with intermediate risk prostate cancer has a high risk Decipher score (10 year risk of metastasis with standard therapy of &...
Micrometastatic disease clearance is essential to prevent late relapse. This approach is often undertaken at centers in Ontario and the UK, though lit...
Do you view creatinine clearance of 40 mL/min as the new cutoff for "cisplatin eligibility"?
Given interim analysis of PEACE V-STORM; also institutional data from SHARP consortium of using 25 Gy/5 fx for pelvic lymphatics. Can we extrapolate?
If the majority of lesions are PSMA positive lesions, do you proceed with Lutetium, and if so, how do you treat or consider therapy to the PSMA negati...
Would you consider adding docetaxel to ADT and novel hormonal agents?
I had two prostate cancer patients recently take ivermectin against medical advice. Both of them had their PSA drop by 2-3 ng/ml. Are you seeing this ...
If a patient has clinical or biochemical progression while on either of these radiopharmaceuticals, would you stop the treatment or continue?
Would you offer definitive radiation/chemoradiation if he is refusing cystectomy?
RADICALS-HD trial (ESMO 2022) demonstrated metastasis free survival benefit with 24 months compared to 6 months of ADT.
How do prior chemotherapy, site of disease, and pathological staging inform your decision?
How about molecular markers (PD-L1, ctDNA)?
Would you treat similar to small cell carcinoma? What is the suggested chemotherapy regimen? Will you continue ADT?
Previously progressed on platinum and Pembrolizumab
In particular, in the modern era of multi-parametric prostate MRI and PSMA-PET, certain findings such as EPE, SVI, or pelvic lymphadenopathy may be no...
Are there specific AR Pathway inhibitors that can be crushed and used through feeding tube or would you just avoid ARPIs in such patients?
Do you offer regular treatment breaks and if so, what is the interval/schedule you recommend?
Which patients specifically benefit from both mpMRI and PET-PSMA?
Given the results of RADICALS-HD and RADICALS-RT trials, it seems as though there was no benefit to adding ST-ADT to RT, but a DFMS benefit for LT-ADT...
Efficacy and cardiovascular safety appear similar per the PATCH trial updated at ESMO 2024. How would you counsel patients who decline LHRH agonists?
NCCN guidelines suggest systemic therapy only or concurrent chemoradiotherapy. What is your approach?
If a patient presents with de novo oligometastatic (i.e., meeting STAMPEDE low met burden criteria) prostate cancer with no prior history of primary t...
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?
If a patient is considered high risk for surgery, with another primary cancer (HCC) and has an incidental renal finding that is highly suspicious for ...
Data from Massard et al., PMID 20181575 used an abbreviated 3-day course of EP with completion of EP and bleomycin at day 15. Should this approac...
For example, if MRI revealed prostate-confined disease but PSMA had moderate avidity in the bilateral seminal vesicles, would you obtain further biops...
In non-FGFR mutated patients, would you use cisplatin/gemcitabine or sacituzimab govitecan at this point?
Two recent studies show the benefit of up-front abiraterone for metastatic castration-sensitive prostate cancer, although these studies used control a...
FDG PET, Axumin PET, Bone scan? Or just proceed with salvage ADT/RT?
Does the interval of monitoring change if given with a concomitant immune checkpoint inhibitor?
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.
When and how are you incorporating tumor sequencing to plan treatment of metastatic prostate cancer?
Given the FDA approvals for PARP inhibitors and combinations in mCRPC, when do you obtain NGS for mCRPC? Do you have a preferred assay?
Would you be willing to treat an elderly patient on blood thinners who has PSMA+ PET, elevated PSA, and multiple urologists have deemed biopsy too ris...
Would you reduce dose prior to adding supplemental oxygen?
Are there specific patients where you're more apt to continue versus holding IO while continuing TKI?
With the advent of PSMA PET/CT, this is my study of choice for high risk prostate cancer. Are there scenarios where standard FDG PET is useful? For ex...
mOS was 53.7 in experimental v. 54.3 in control; however ORR 71.3% vs. 36.7%, and mPFS 23.9 mo vs. 7.2 mo (HR 0.47). Does the lack of OS benefit sway ...
Adjuvant IO therapy, radiation therapy, both, or neither?
Do you start neoadjuvantly? Concurrently?
Long-term ADT is deleterious to multiple organ systems (bone/sexual/psychiatric) and increases the risk of MACE. What level 1 evidence do we have to c...
On the EMBARK trial (Freedland et al., PMID 37851874), 25% of men had a prostatectomy and the publication states, "Patients were excluded … if ...
The NCCN lists concurrent chemoradiotherapy as a primary treatment option in these patients. If so, what total dose do you deliver to involved ly...
STAMPEDE answer is yes, intuitively it seems there must be a line somewhere though.
For patients staged only with PET that is widely M1, should a CT ...
Would treatment be palliative (i.e. for ureteral obstruction) or definitive? Is there a role for chemotherapy or hypofractionation/SBRT?
Current NCCN guidelines recommended not combining relugolix with these agents until more data is available.
Any drug interaction concerns or ot...
Given the limited # of patients with PALB2 mutation on the PROfound trial (de Bono et al., PMID 32343890) and the benefit primarily driven by Cohort A...
If using adjuvant chemotherapy, should the patient receive carboplatin or use a more intensive regimen because of the positive margin status?
With that smoking history, wanting to avoid BEP.
Patient has multiple adverse features on pathology, however, PSA just became detectable one year after surgery. SPPORT included patients with PSA>0...
KEYNOTE-564 required CrCl 30 or above. Not having a baseline/stable CrCl may make it difficult to diagnose or treat IO nephritis.
Do you insist on ambulatory/home blood pressures to rule in/out white coat hypertension? Does your practice have a system to log patients' BPs to supp...
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...
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical prac...
If a patient has already received ADT+ARSI would you use PARPi over chemotherapy in 2nd line?
Are there any precautions or pre-medications that may permit this treatment in patients who are fit for therapy but have exhausted all other treatment...
ARSI may be controlling a hormone sensitive clone. Some patients flare after stopping the drug.
Would a PET avid pelvic lymph node without distant metastatic disease change your management?
How would it change your risk group or management? Does Decipher help further inform treatment?
Many options for vasomotor symptoms of menopause do not work well for men on ADT. However, fezolinetant is a neurokinin B blocker, so theoretically, s...
I have a pair of patients with MRI+ and biopsy+ disease who have staging PSMA PET/CT that do not show disease within the prostate (or anywhere else).&...
When (if ever) would you consider immune checkpoint inhibitor up front? Would you be less inclined to offer triple drug therapy? (Some thought that ta...
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...
Are there any chemotherapy regimens that can be used in elderly patients with poor PS who are not candidates for BEP?
Does obstructive hydronephrosis allow for clinical upstaging to stages 2-3?
If baseline testosterone is at castrate levels (e.g. <50), would you consider patient to have castrate-resistant disease?
For instance, do you factor availability of RNAseq, inclusion of normal blood controls, and QNS rates into your decision?
Has this recent retrospective analysis published in Lancet Oncology changed your practice?
How are you incorporating CONTACT-03 data presented at #ASCO2023 (Pal et al., PMID 37290461) into your practice? Would you consider immunotherapy re-c...
How does margin positive influence your decision?
Do you preferentially use Ra-223 first given the RALU study?
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?
Do you routinely check tumor markers between cycles when managing NSGCT?
Will you use it rather than a carboplatin-containing regimen?
Do you feel comfortable stopped abiraterone after 2 years?
Are there concerns for under-staging with bladder cancer in diverticulum?
24 months ADT + abiraterone + definitive RT is indicated for cN1 disease but not for pN1 disease per NCCN. Can the data be extrapolated to this popula...
Notably, the patient presented with renal failure due to ureteral obstruction and hydronephrosis, receives hemodialysis, and has limited systemic opti...
If so, which checkpoint inhibitor would you use?
Do you also give neoadjuvant, concurrent, and adjuvant ADT in the same manner as for non-SBRT EBRT?
Pretreatment PSA 25.3 with Gleason 4+3=7 and MRI suspicious for ECE. Eight months after pelvic nodal and prostate XRT to 79 Gy, PSA is 5.02 (down from...
A recent NCBD analysis (Rusthoven et al., PMID 27325855) suggests that the addition of prostate RT significantly improves survival compared to AD...
Specifically if metastatic risk estimate approached the failure rate in control arm of STAMPEDE for high-risk non-metastatic disease (69% MFS at 6 yea...
If so, how long are they on degarelix before the switch?
Bleomycin omitted due to asymptomatic decline in DLCO
Please specify how your institution is allocating resources now or will be soon.
Based on GI regimen or urothelial carcinoma regimens?
Would you biopsy lymph node to confirm recurrence/histology?
If confirmed, how do you decide between RT vs chemotherapy? If chemo - BEP x3 vs E...
If ADT +/- ARPI + RT, what duration of systemic therapy do you recommend?
Assume the patient is not a candidate for surgery. What dose would you use? Would you recommend a lower dose to not damage the patient's kidney functi...
If the patient received <2 months of immunotherapy, would you continue immunotherapy alone or transition to enfortumab monotherapy or EV+Pembro?
Are there exceptions?
What imaging modality do you use (conventional, PSMA PET, etc.)? When do you image (ex: a PSA threshold or PSADT)?
Would you consider these as metastatic sites? Would you biopsy to confirm?
Would you switch to enzalutamide or apalutamide if not giving docetaxel given darolutamide data for mCSPC is only from ARASENS trial with docetaxel?
Would you prescribe ADT for a patient with dementia who has biochemical recurrent, non-metastatic prostate cancer, but otherwise good physical PS?
Would you consider using an IO-based treatment or move on to TKI? Does the presence of sarcomatoid or rhabdoid features impact your approach?
When do you order PSMA PET? Do you preferably order Locametz (gallium Ga 68 gozetotide) PET?
PSMA PET vs Conventional imaging vs combined imaging?
Are you waiting for BCG to become available or are you using other bridging therapies such as pembrolizumab?
Is this stage IS or IIA? Is chemotherapy or RT preferred?
Do you wait for radiographic progression? What is your preferred imaging modality for re-staging?
How do you decide between downstaging chemotherapy or upfront concurrent chemoradiotherapy? Both are listed as NCCN options.
How would you treat such a patient?
For a patient, who has received SBRT & WBRT for CNS disease, is there a role of autoSCT and HD-chemo in this setting (no residual extra-CNS diseas...
General recommendations on dose and management presuming unresectable.
Would surgical margins, evidence of angiolymphatic spread, number of lymph nodes removed during surgery inform your decision?
What would you use after platinum/taxane/IO first line therapy?
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.
Would you avoid combination with TKI given possible higher risk of osteonecrosis of the jaw?
Would you switch to VIP or TIP? If so, how many cycles?
Very rare tumor with sparse literature
How reliable is somatic testing to detect an underlying germline predisposition?
Any role for adjuvant therapy? If so, with what agent?
Is there concern for increased toxicity from erdafitinib following avelumab similar to osimertinib toxicity following pembrolizumab in NSCLC? Does FGF...
Would you use an FDG PET to further inform decision?
Would you treat with ADT if no metastatic disease?
Does absolute PSA (e.g. PSA<2) inform decision?
Does ADT affect the results of a biopsy?
If so, do you use it for all patients or only cisplatin doses >= 70 mg/m2? What dose of mannitol do you use?
Additional imaging of the potential lesions, biopsy or assume negative given normal PSMA PET/CT.
Does specific mixed histology variant change recommendation?
Or would you proceed with cabazitaxel or other therapy? Initial chemo-hormonal therapy was ADT + Docetaxel x6 cycles.Docetaxel rechallenge at time of ...
Do you find the ibPFS endpoint sufficient to change practice for any or all patients, or will you await OS or other data/trials?
Alternatively, is a biopsy of a metastatic bone lesion preferred in a patient who has already progressed on chemo and hormonal therapy and has bone-on...
For example, in a patient on steroids for CNS or spinal metastases - would you use IO-IO vs IO-TKI or TKI monotherapy?
How do you differentiate between olaparib, rucaparib, niraparib, talazoparib?
If yes, would you directly add olaparib at progression on abiraterone vs waiting to use abi/olaparib at a later line of therapy?
Is the benefit in PROpel driven by BRCA1/2 or ATM mutated tumors vs all comers?
Would you offer adjuvant radiation? (Dose? Target?) vs Salvage?
Would you add ADT? Would you add abiraterone?
Would the number of lymph nodes involv...
Would you consider using them in patients with CHEK2 mutations?
Do you have a preferred way to incorporate advanced androgen blockade vs chemo vs sip-T vs Lu-PSMA vs PARP vs other targeted agents?
Is prior Ra-223 a contraindication for treatment?
Patient has ED unresponsive to cialis/viagra; would you recommend testosterone replacement therapy?
If you do recommend adjuvant therapy, what regimen would you use?
What were your “top 3” presentations/studies coming out of the meeting this year and how will it impact your own clinical practice?
Do you have a preference for bicalutamide? Can abiraterone be used instead?
At what PSA would you become suspicious for biochemical recurrence and pursue restaging? Is there a threshold value?
What imaging modality would you ...
NCCN states to consider adjuvant chemotherapy similar to muscle invasive bladder cancer in this scenario, but one would avert adjuvant chemotherapy in...
Would you use it for initial staging or at time of biochemical recurrence?
If radiation, what type? EBRT or brachytherapy? Any other techniques you would recommend, such as rectal balloon?
Any data to support this combination for non-clear cell RCC?
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...
Would T or N group change your recommendation?
Would you treat with adjuvant chemotherapy or immunotherapy?
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 trial inclusion criteria was essentially "docetaxel candidate per the treating oncologist"
If serum markers were normal, how strongly do you consider 1 cycle of BEP for embryonal predominant pathology?
Is there a concern regarding rarer side effect emergence (cardiac, bone, muscle, cognitive) of long term exposure to "maximal" androgen deprivation? I...
The forest plot from CheckMate 274 did not show a benefit for such patients?
How would you select between adjuvant chemotherapy and adjuvant nivoluma...
VIP can be considered, but given complex psychosocial issues and limited community cancer treatment resources, this question is being asked.
Would you consider boosting the nodes? What dose? Would this change your recommendation for length of ADT?
Would you consider chemotherapy, androgen blockade or triple therapy (chemo and AR targeting)?
Would you consider re-challenging with a different TKI?
NCCN guidelines state check at baseline and then as clinically indicated. Some other sources state, can check prior to each cycle of BEP?
What ...
HCG 850, AFP normal, LDH ~500 pre-orchiectomy.
If tumor thrombus, would you favor 4c of BEP? Would you try biopsy it? How common is IVC thrombu...
Would the results of PEACE-1 trial justify this?
Is a 3 month delay too long in someone who had postoperative complications?
Are there clinical features (post-op PSA, Decipher score, pN+, pT3, etc) that would inform your decision?
Do you worry about false negatives on PET, CT, MRI if ADT is started before the scan? Scheduling scans can sometimes book 2-4 weeks out.
Would you treat with PARP inhibitor or Check-Point Inhibitor?
Given persistent embryonal histology on RPLND, do you favor observation or TIP/VIP? What do you use to guide your decision?
Is Crohn's diagnosis an absolute contraindication for immunotherapy?
Does PDL1 status impact your decision?
Does severity of dementia play a factor in recommending ADT?
NGS of TURBT specimen had high TMB (18 Muts/Mb).
Do you observe, offer adjuvant pembrolizumab, or give a first-line metastatic regimen (IO/IO or IO/TKI)? Does your recommendation vary based on risk c...
Is there a role of EBRT to the prostate with extended fields to cover the retroperitoneal nodes plus ADT (definitive therapy) or would you treat as ca...
Would you do consolidation radiation or active surveillance?
Would presence of variant histology change your recommendation?
PSA rose from 25 to 30 ng/mL over 6 months on darolutamide for M0 CRPC, prompting scans which showed oligometastatic disease to bone, not amenable to ...
If yes, how many cycles?
How do you weigh the various efficacy endpoints in the trials of novel combinations in ccRCC?
Are there specific clinical populations that you ...
Do you give adjuvant chemotherapy to a patient with a completely resected mediastinal pure seminoma?
What is your approach to a patient who underwent surgery for what was thought to be a thymoma, but ended up being a pure seminoma? No disease elsewher...
How would need for anticoagulation change your consideration?
Does disease response (CR vs PR vs SD) or IO-TKI combination factor into your consideration?
Would you think differently about chemotherapy based on %teratoma or size of lymph nodes vs number of lymph nodes (eg. multiple small LN vs single 2-5...
If not carboplatin, would you recommend nivolumab instead?
When is the optimal time (if ever) for cytoreductive nephrectomy?
Or with other available IO/TKI combinations should this be strictly reserved for intermediate/high risk patients only?
If selecting IO/TKI, do ...
Or what is your preferred regimen for stage IV ccRCC following progression on IO/IO?
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.
Do you select treatment based on toxicity profile since efficacy of regimens will likely never be directly compared?
Are there QOL indices that can ...
Patient has progression of liver metastases while on pembrolzumab/axitinib. ECOG PS 1 and limited comorbidities.
Or would you restrict such treatment to patients with known pathogenic germline BRCA mutations?
Given ductal histology, is docetaxel preferred over NHT?
Are there other high or very high risk features that would also contribute to your decision making?
GS 4+4. PSA low (1-2). CT and bone scan negative for lymphadenopathy or metastatic disease. Prostate MRI pending.
The recommended concurrent chemotherapy regimens (cisplatin/paclitaxel and cisplatin/FU) in NCCN are based on BID fractionation of radiation as in RTO...
Patient previously had prostatectomy and salvage RT
How would non-regional adenopathy change management? What about poor surgical candidacy?
Would you recommend surgery first or neoadjuvant therapy such as concurrent cisplatin/RT or another regimen?
Did you change your practice given the SRE results in the control arm of EORTC 1333 at ASCO 2021?
When using bisphosphonates or denosumab, what dosin...
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?
When do you use mitotane?
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...
Do prior treatments for mHSPC change your thinking on whether or not to use sipuleucel-T?
Patient has not had any prior systemic treatment and is cisplatin-eligible.
Would active vasculitis present a contraindication to therapy?
In reviewing the data, LDH does not upstage to intermediate risk but those patients tend to do worse.
Would one treat this patient as intermediate ri...
Are there any clinical features that can inform etiology/which medication to hold?
No targetable mutations detected
Negative surgical margin, normal post-orchiectomy markers and no lymph node and distant metastasis
In addition to ADT, would you treat with abiraterone, enzalutamide or docetaxel? Or other treatment - platinum/taxane?
Is DFS benefit in KN-564 in ASCO2021 sufficient evidence to change practice?
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
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...
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?
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?
HERO study - https://clinicaltrials.gov/ct2/show/NCT03085095
i.e. Cisplatin + Etoposide
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...
Do you offer EPO and TPO support? Do you modify your systemic therapy up front or after subsequent cycles?
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?
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?
Per the ALSYMPCA study, they excluded patients with > 3cm lymphadenopathy. Patient is currently on enzalutamide and leuprolide and refuses docetaxe...
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?
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?
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?
Is microscopically positive renal vein margin an indication?
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?
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...
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...
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 start it?
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...
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...
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...
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The Journal of urology, 2005-08
Mol Clin Oncol, 2015 May 04
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JAMA oncology, 2016-04
JAMA oncology, 2017-01-01
JAMA, 2009-08-26
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Cancer immunology, immunotherapy : CII, 2016-08
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The cancer journal from Scientific American, 2000-02
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The New England journal of medicine, 2016-12-08
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Medicine (Baltimore),
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JCO Precision Oncology, 2017 May 31
The New England journal of medicine, 2016-08-04
NEJM Evidence, 2022 Jun 3
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The New England journal of medicine, 2017-03-16
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The New England journal of medicine, 2003-08-28
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