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Interview with Prof. Arnaulf Stenzl at EAU 2017 - News in immunotherapy and combination therapy in urothelial cancer
Professor Arnaulf Stenzl MD
Chairman, EAU Congress Committee
Professor and Head of Department of Urology
Eberhard-Karls University, Tubingen, Germany
The urothelial cancer in the majority of cancers, fortunately, can be treated locally or regionally. However, we do have aggressive tumours, we need to have a molecular pattern of those tumours in order to know how much forms or how much treatment a patient needs, because some of that treatment may be not only invasive with regards, for example, to cystectomy, but it may also need chemotherapy or systemic therapy before or after, and so we need to decide which patients, at an early stage would need more treatment than other patients, and that treatment sometimes does have side effects but it will increase the chance of survival of this patient.
The new substances are focusing on the immune system. They will try to avoid the blockage of the T-cells and immune system by the tumour, and these so-called PD1 or PDL1 or PDL2 substances are showing better results than the common cisplatinum-based combination therapy, and they also have less side effects.
Unfortunately, not all of them are acting on urothelial cancer but we are trying again to see which patients might respond better to immunotherapy or checkpoint inhibitor therapy and which ones may be better candidates for a normal or a conventional cisplatinum-based chemotherapy.
The other thing is of course the sequence of the therapy, the sequence of not only the combination chemotherapy and the checkpoint inhibitor therapy but also the combination and the sequence between surgery, radiation and the systemic therapy is what we are exploring right now and we are seeing definite advantages, especially in those patients that cannot have a normal cisplatinum-based therapy because of renal insufficiency or because they have other morbidities that prevent them from having a toxic and side-effect prone platinum-based chemotherapy.
So, it's exciting. The take-home message is we need to insert this new therapy because of less side effects probably at an earlier stage than we had before or we can use it for patients that are not suitable for cisplatinum-based therapy and that in the upcoming years and with new substances coming up, we'll have to find the right combination because we can and we will combine it, both with surgery, radiation as well as other systemic therapy, and on the other hand we will see how the sequence may benefit, may be a benefit, for the patients, both side effects and the actual outcome of urothelial cancer.
Urothelial cancer can be usually treated regionally using traditional approaches such as radiation, surgery and cisplatin based chemotherapy in majority of the cases. However, in case of aggressive tumours, discernment of their molecular patterns early in therapy might be a better approach to help decide the quantity and sequence of the various available approaches mentioned earlier. Recently, there has been an immense focus on checkpoint inhibitors such as PD-L1 which avoid the blockage of the immune system by the cancerous tumour. This treatment option either alone or in combination with other forms of therapy should be considered in the early stages of the disease especially in patients who cannot tolerate cisplatin based therapies. This interview with Prof. Stenzl focuses on the new wave of checkpoint inhibitors and what value they add to the oncology treatment arsenal.