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So I'm here today with Doctor Shawn Dawson and we're going to be talking about the latest advances in genitourinary cancers from Moscow. Just to, to kick off, Doctor Dawson. Would you, um, would you mind giving us just a little glimpse of your research interests and a little bit about your career background? Yeah. So, uh, yeah, I'm a urologic oncologist at the Ohio State University in Columbus, Ohio. Um, we focus as urologic oncologists on surgery for kidney cancer, prostate bladder testicular. Um I'm a little bit more focused on the kidney side of things and I have a lot of interest in, you know, surgery for advanced kidney cancers that involve the IBC or surgery and metastatic disease. Um, that pretty much mirrors my research interests. Uh, and, and so I think, uh, you know, that has been my main focus at the meeting, but I certainly also deal with a lot of prostate cancer, bladder cancer, and uh, and testicular cancer. So I love to talk to you about all of that today. Uh, really, really, um really excited to have this conversation. What do you feel are the greatest takeaways from Oscar this year when it comes to genitourinary cancer. What was everyone talking about? I think, uh you know, really my perspective is going to be again um from the perspective of a surgeon. But one of the biggest advances was a study that looked at the role of extended lymph node dissection in bladder cancer. Um Basically, there's kind of a dogma, I guess you could say that the more lymph nodes the better in radical cystectomy for muscle invasive bladder cancer. And historically, we thought, you know, the kind of the more extended dissection that you do if you extend your limits outside of the true pelvis, but higher into the region of the aortic bifurcation or even the inferior mesenteric artery. Um you could potentially, you know, be curing more patient's with advanced bladder cancer. And so I think that um there was still a mixed practice pattern, but there was a bit of a move that an extended lymph node dissection uh predominantly based on observational data was, was favorable. Um a couple of years ago, I guess, maybe four or five years ago. Now, we had a German study, a randomized trial that was published that looked at um extended versus a standard lymph node dissection and actually didn't find um a survival benefit at the time. There were some limitations in that study and how it applies to our current practice and some differences in the dissection templates um from what we might do, you know, kind of contemporary Lee. And so some of those criticisms maybe led to that not being widely accepted as the final word on things. Um But we now have an updated study that was just presented for the first time at Asco. Um Basically a swab study that randomized patient's getting a radical cystectomy to either have an extended lymph node dissection where the template of lymph node dissection is extended up to the aortic bifurcation including uh packets along the common iliac vessels, including presacral vessels, uh precycle kind of sorry packet. And um that was, I guess the extended group versus the standard group, which did not include those just included a standard pelvic lymph node dissection. Um And with that, with, there was a finding that there really was not a difference in uh recurrence in cancer specific survival. Although there were more lymph nodes removed. I don't think this translated necessarily into clinically relevant outcomes. Um I think that's a big shift because again, practice patterns did very slightly. But the extended lymph node dissection in bladder cancer is something that is pretty commonly performed in my experience. Um And so I think we'll probably see based upon that move to reduce the lymph node dissection. Now, that's probably important because we're uh seeing that, you know, in the same trial, there was a higher rate of complications by extending the lymph node dissection, which kind of follows that, you know, more surgeries being performed and that mirrored the prior German study uh that, you know, there were also higher complication rates in the extended group. So I think that was probably if I were to say one take away the biggest takeaway uh for me, um I think that would be the biggest one in bladder cancer. But there was also updated data on um neoadjuvant dose dense em back in the um again, neoadjuvant setting compared to gemcitabine and CISplatin. Um You know, there was definitely, I guess prior data to support that, that may have a role in improving outcomes, but they're, I guess was more long term follow up of the Vesper trial that was presented. And, you know, it really kind of brought that again into the debate as to whether we should routinely be using dose dense em back versus gemcitabine insist Platon. Um It's again something I think where although the study, the study was previously presented and, you know, there is certainly reasonable data to support dose dense evac uh practices, I think varied on that. And a lot of Gemcitabine and CISplatin was in use again. Um You know, I think we'll still see that there's a bit of a broader, um I guess spectrum of what people are using for new adjuvant therapy. But I think this kind of longer term follow up with an improved overall survival in the uh new adjuvant Dustin's em back arm, um might shift practices in the younger healthier patient that's able to tolerate the six cycles of what might be a slightly more intense treatment, um, really to kind of favor that approach. Um Shall I kind of continue with some of the other cancers or? Yes, we've, we've, we've, we've talked about bladder cancer. What about the other kind of genitourinary cancers? What, what, what, what was everyone talking about? Um, I think in prostate, uh, there were two studies that were interesting, at least to me from, from my readings. The first was uh a randomized clinical trial called the peace study that looked at the role of radiotherapy in the treatment of the primary tumor in low volume metastatic hormone sensitive prostate cancer. Um in prostate cancer, there's kind of been this unique and interesting um concept in the past few years, which is really to look at uh treatment of the primary tumor, the prostate in the setting of metastatic prostate cancer. And, you know, this was conventionally something that we never thought was, you know, um appropriate. But I think a couple of different studies looking at that and perhaps even supporting that have brought that into prominence lately. So, uh a couple of years ago now we had publication of the Stampede trial which um you know, was a trial conduct in the UK that um had over I believe 800 patient's in the low volume metastatic hormone sensitive prostate cancer group. See a significant survival advantage associated with radiation to their primary prostate cancer um compared to no radiation. And so that really, I think made that a fairly reasonable standard for this group of patient's mainly those that are presenting with hormone sensitive prostate cancer that's metastatic to uh either no visceral metastases or um kind of the bone definition is less than for um without anything outside of the axial skeleton. So no appendix color lesion's and um you know, four or less lesion. So there's a bit of a technical definition there. But um that uh you know, I think was quite uh standard for the past few years. What was released at Asco was the results of the peace trial? Um And what that demonstrated was that radiation to the primary tumor in combination with androgen deprivation treatment and abiraterone um improved radiographic progression free survival. Uh And I think that that is a new finding because previously the Stampede trial was only with androgen deprivation therapy at a baseline. It didn't have the addition of abiraterone and there was a bit of a question, a conversation as to whether the two were independently contributing in this space or whether it was kind of dealer's choice, one or the other. Uh Additionally, what was interesting was that in the same piece study that was kind of presented, they didn't have a benefit of radiation and combination with androgen deprivation alone. Now, I think a lot of people would say that that's no longer are standard for metastatic prostate cancer but it did raise a question as to why the Stampede trial was positive, but this trial was negative in that kind of space. And I think from a uh overall trial landscape standpoint, we have a large study in the U S that's running called swag 18 oh two, that's looking at the role of radiation and, or surgery in the metastatic setting. And there were some comments that maybe this trial was unethical in the setting of the publication of Stampede that showed a benefit, you know, so it was a question while we already shown a benefit in Stampede, why are we randomizing people to receive nothing in the control arm to their local tumor? Um But this study now, I think kind of brings into the mix. Well, we have now some data to say that hey, treatment of the primary tumor was not beneficial even though it was seen in Stampede. Um at least in the ADT only arm. How do we explain this discrepancy? There's actually a third study called the Horrid study conducted in Europe. Uh that was also negative. And so I think it provides almost a little bit of um rationale to say that, hey, this American study is not so unethical ist was maybe being put forth before it, it actually is gonna maybe contribute to the field. So it um I think it's interesting data to support the role of radiation in the setting, but also to support the role of the S 80 know to study in this setting. So, um you know, a couple of useful takeaways from the piece, one presentation, um a little bit of a smaller study, but there was also a, a study looking at the role of um abiraterone and apalutamide based on race in metastatic castration, resistant prostate cancer. And, you know, we kind of have a sense that there are definitely differences in prostate cancer based on race. And um you know, whether the underlying reason for this is disparities, whether the underlying reason for this is something else, that's certainly a big focus on, you know, prostate cancer research just because in the U S, you, you know, you may or may not be aware, but the rate of prostate cancer is about twice as high in men. African American men as compared to white men and the rate of death from prostate cancer is similarly elevated. And um you know, that disparity in outcomes is something that's been a big focus of prostate cancer research. Um I guess, especially in the last 5 to 10 years. And uh you know, we certainly see a lot of it relates to access to care and, and other measures like that. But um what was interesting in uh the data that was presented at Asco in this specific Panther study was that although the groups were generally reasonably balanced, the rate of um this kind of therapy working in black men was much higher than in white men. Suggesting that there might be a bit of a difference in treatment efficacy based on some factors like this. And this actually supports some other prior data. You know, I'm aware of a meta analysis looking at the um DOCEtaxel which is a chemotherapy, uh finding that it's more effective in men, African American men compared to kind of control white men. And you know, it begs the question as to uh could we be doing anything differently to improve outcomes in that group? You know, because uh I think really that's a big focus of prostate cancer researchers. We kind of know there's a lot of disparity there. So, um I think if I were to say that was the second takeaway in prostate cancer, that was probably a good one that the uh you know, androgen uh manipulation in the treatment of prostate cancer may differ based on race. And we really have to come up with more personalized. Um I guess medicine related uh predictive biomarkers or um treatment paradigms uh to improve outcomes overall. Um when it comes to kidney cancer, I think that there was nothing that is going to actively change practice today. There's a lot of promising data to say that um you know, we're going to be hopefully doing things differently in the future. Uh I was part of an educational session where we talked about the treatment of illegal metastatic um renal cell carcinoma talking about the surgery, um, aspect of that. And, uh, you know, I think that not a lot has changed or will change in the short term when it comes to thinking about how we approach doing nephrectomy side productive nephrectomy in renal cell carcinoma or uh metastasis ectomy in renal cell carcinoma. But there's a couple of really um important clinical trials, the probe study in North America and Nordic Son in Scandinavia that I think are really gonna hopefully in the coming years bring us um clearly on when to perform cytoreductive nephrectomy in the setting of metastatic RCC. Um you know, a lot of promising trials looking at radiation treatment in renal cell carcinoma that although not yet reported, I think will really change the field in the coming years to um at my session. One of my colleagues, uh Dr Hanan presented the schematic for the sore trial which will open soon, really looking at radiation to the treatment of illegal Metastatic RCC. You know, I think a lot of us feel that there's a strong rationale to support this in delaying systemic therapy, improving quality of life. And you know, when that trial opens and, and you know, eventually years from now reports, I think we'll really see that become a part of the standard for our CC. A lot of the presented data in our CCI think reflected the significant advances that we've seen in years past um in providing longer follow up for that uh kind of uh clinical trial um barrage that we've seen in prior Oscos, for example, you know, longer term follow up was presented for um the clear study which looked at Lenvatinib and Pembrolizumab and really provided uh phenomenal overall response rates. And, and another treatment uh you know, are kind of armamentarium for metastatic clear cell RCC. Um We had uh I guess subgroup analysis of an adjuvant trial that was not positive. The IPI Nevo study. Um you know, trying to see if there was some subgroup there that would eventually um kind of show us uh where this treatment might be beneficial. I think it was interesting that they saw that it was beneficial in sarcomatoid uh patient's that, you know, have a really high risk of recurrence. I think a lot of us have a sense that those of the biggest uh kind of target for some of these new immunotherapies in the address in setting or even in the Metastatic setting. And so, um uh perhaps it provided a rationale to kind of keep looking at some of these subgroups for adjuvant treatment. Um Yeah, I think those would be the two big takeaways from reno uh testicular. We typically don't have a ton, I don't think there was a ton of practice changing data this time, but there was certainly a study, the Sweetness Tech Sueno Tecca study uh that provided an additional series to support the role of retroperitoneal lymph. Don't dissections in metastatic seminoma. Um We currently have several series now, uh recently, the same study um was published in the journal of Clinical oncology and presented at the janitor urinary asco um kind of earlier in the year and uh other data from Europe. And now the sui know tecca kind of adds to that that um you know, retroperitoneal lymph node dissection is a primary treatment for metastatic seminoma is probably a very reasonable option allowing patient's to avoid chemotherapy and radiation therapy, which in this group of really young patient's that develop seminoma may have long term implications for um cardiovascular toxicities, secondary malignancies, other toxicities that would be hopefully avoided by retrofitting a lymph node dissection. So I think that that about rounds it up again, I have a bit of a surgical uh kind of perspective on it. Um But uh a lot of uh you know, great work, a lot of promising new avenues for future rascals. Um But those would be the biggest takeaways for, for me. Uh what a brilliant summary of general urinary cancer at, at Asco. Uh Doctor Dawson, thank you so much for uh for showing that that with us just as a really quick glimpse into the future. What do you think are the kind of things that we should be looking out for over the next 12 months that we might expect to see happening at Asco 2020 for what are the hot topics that that people are talking about in this, in this space that are, are perhaps currently ongoing. What research is currently ongoing and, and what should we expect that next year's asco in general, you know, the cancer? Yeah, I think we're really going to see um a lot of advances in systemic therapy. I mean, that's the nature of the field. Um on a surgical end, I don't think we're gonna see very much come about in the next year or next few years. And that's okay because, you know, the advances on the medical end are really helping us in the surgical clinics too. Um when it comes to thinking about um prostate cancer, I mean, the barrage of new agents um and where they fit in the overall treatment paradigm, I think it's really gonna be uh kind of key, you know, we've got to figure out a little bit better who we need to proceed with triplet therapy for at the diagnosis of metastatic hormone sensor prostate cancer. We've got to figure out a lot of the disparities associated with um prostate cancer research. Like we know that um you know, men that are uh of African American descent, as I mentioned, have all these adverse outcomes um and are really not getting the same um access to care. They're not getting the germline testing to look for the treatment of parp inhibitors. They're not getting um kind of some of the treatments that we think are part of the standard. And I think uh figuring that out on a population level is becoming more of a priority, especially in, in Asco and uh in North America. So I think um that will be a big part of what we see in the coming years. Um The other side of things is uh I guess figuring out how to combine more agents, perhaps new adjuvant therapy in high risk localized prostate cancer with some of these new agents to bring them earlier into the treatment space. Uh not so much at this asco but at genital urinary Osco, uh you know, there were data presented on some of the new adjustment um kind of uh treatments and and the possibility for significant total androgen blockade to induce a market response prior to prostatectomy. Uh I think we're awaiting the results of the proteus trial, um which is kind of looking at that in a large um randomized fashion. And I think if that is positive would really significantly change the landscape in how we treat high risk localized prostate cancer. Uh that should probably report soon. And it's kind of in the theme of a lot of these medications and bringing them into different spaces and bring them earlier or later. Um when it comes to bladder cancer. Um I mean, the biggest things we're seeing there are the antibody drug conjugates. Uh you know, the combination of in four to map for gotten and pembrolizumab just received FDA approval. And I think uh the data to support some of these um and hopefully bring them earlier. Hopefully, the data that they would be actually improving clinical outcomes in phase three studies is um coming soon, the kidney side of things. Um you know, I think it's hard to know what the next uh directions there that are going to really change practice are we've had just this um you know, huge advance in the past five years. And that includes, you know, four new front line therapies that includes a new approved adjuvant therapy. Um There are, you know, innumerable ongoing studies, but it's hard to know what is actually going to change practice after we've seen such an advance recently, you know, is the, I guess next five years going to bring the same degree of advancement or are we gonna stay stable a little while and let the drugs that are in earlier settings? Um, kind of catch up a little bit uh to get those phase three trials out. But, you know, whatever it is, the future is bright. It's just, it's hard to know what exactly is going to change practice next year in, in kidney cancer. Um, on the surgical end, it's certainly nothing that I'm aware of that's going to be reported in that timeline on the medical. And I'm sure that, you know, we will be seeing advances soon. We're participating a number of different clinical studies that I think you know, might very well change practice very soon but um hard to know what the results will be and what the timelines will be like. Uh Doctor doesn't thank you so much for your time today. Um It's, it's really great to uh to hear your opinion on, on what were the hot topics and the hot papers in genitourinary cancer and I'm sure will stimulate a lot of discussion. Thank you so much and we really appreciate it. My pleasure.