Bladder Cancer Flashcards
Chronic cystitis can be a risk factor for bladder cancer, what can this be seen in? Which type of bladder cell cancer can this be assoc with?
Those with chronic indwelling foley cath. It causes squamous cell bladder cancer. Don’t forget that pelvic RT can be a risk factor as well besides smoking, cyclophosphamide, and occupational hazards (aniline dye, vinyl). Don’t forget that lynch syndrome causes upper tract cancer.
What is the def of muscle invasive bladder cancer?
T2 lesion or higher, muscularis propia involvement
For those that have muscle invasive dx what are the tx options in terms of neoadjuvant dx for Stage II patients? T2,N0
They can get a neoadjuvant chemo regimen (ddMVAC or Gem/Cis) followed by radical cystectomy or partial cystectomy (only for for those with a solitary lesion and no Tis).
For those patients who are not candidates for cisplatin what is the best next step for stage II and IIIA?
Cystectomy alone
Who is eligible for cisplatin?
ECOG less than 2, or KPS of 70% or more. Creatinine clearance of 60 or higher. Less than grade 2 hearing loss and neuropathy. No NYHA III or higher heart failure.
Following cystectomy what adjuvant therapy is indicated if they didn’t receive chemo?
If pT3, pT4a, or pN+ the preferred option is to give Cisplatin based chemo or you can consider Nivolumab. If chemo was given and they have ypT2-T4a or N+ disease you can give Nivolumab or adjuvant RT in those with with pT3-4 dx, positive margins/nodes at time of surgery.
What can be done for patients who are not candidates for surgery or don’t want to undergo surgery and have Stage II/IIIA disease?
Concurrent/chemo RT w/max TURBT.
For those patients who are not candidates for cystectomy or chemo/RT, what is the next best option? Stage II T2a and T2b w/N0 disease and IIIA: T3, N0 T4, N0 T1-T4a, N1
RT alone
If a patient undergoes chemo/RT if there is residual tumor present what do you do?
Tis, T1, Ta-consider TURBT+/-intravesicular therapy
Persistent T2-consider radical or partial cystectomy or you can treat as metastatic disease
If a patient undergoes RT and still has residual disease?
You consider systemic therapy or TURBT +/-intravesicular therapy
What are the treatment strategies for Stage IIIB (T1-4a,N2/3)
You can start with downstaging with systemic chemo or you can do chemo/RT
What subsequent therapy is needed for Stage IIIB if they had chemo?
If they have a CR you can consider doing consolidation cystectomy, chemo/RT, or surveillance
PR: You do cystectomy, chemo/RT, or treat as metastatic dx
Progression-tx as metastatic dx.
What subsequent therapy is needed for Stage IIIB if they underwent chemo/RT?
CR-surveillance
PR-if they have T1, Ta, Tis consider giving BCG or surgery, or treat as metastatic dx
Progression-treat as metastatic dx.
What is the preferred regimen for first line tx in metastatic dx that doesn’t use chemo?
Enfortumab/Pembro. This is preferred over chemo!
What chemo options can be considered for those that can get Cisplatin?
Gem/Cis followed by Avelumab (PFS and OS benefit)
Nivolumab/Gem/Cis followed by Nivolumab
Dose Dense MVAC followed by Avelumab
What chemo and IO options are available for metastatic dx if they are not eligible to receive Cisplatin?
Gem/Carbo, Gem/Paclitaxel, Gem alone
Pembro-for any patient that is not a candidate for chemo regardless of PDL1
Atezo-for any patient that expresses PDL1 or for any patient who cant get chemo regardless of PDL1.
What is the preferred 2nd line option for metastatic bladder cancer for those who haven’t gotten IO? What are your other options?
Pembro (Cat 1). Can also use Nivolumab and Avelumab. Erdafatinib for FGFR3 alteration.
What options are available for 2nd line tx for metastatic cancer for those who have gotten IO?
Cisplatin eligible: Gem/Cis, DDMVAC, Erdafatinib for FGFR3.
Cisplatin Ineligible: Gem/Carbo, Enfortumab, Erdafatinib
For third line and beyond in metastatic disease know that Sacituzumab can be used and TDXT is approved for Her 2 IHC 3+. Erdafatinib can be used here too.
