2017 Genitourinary Cancers Symposium

gu_symposium_2017_img_3054The 2017 Genitourinary (GU) Cancer Symposium kicked off on February 16th in Orlando, Florida, bringing together more than 3,000 attendees from all over the world. At this annual conference, clinicians from a wide range of disciplines treating people with prostate cancer, kidney cancer, bladder cancer, and testicular cancer come together to hear from experts on the latest scientific discoveries and how they impact clinical care for patients.

The Weill Cornell Medicine (WCM) and NewYork-Presbyterian (NYP) GU Oncology team is down in the Sunshine State highlighting the cutting-edge research and patient care that has been taking place back on campus in New York City.

twitter-iconTeam member Dr. Bishoy Faltas was selected by the conference to be a “Featured Voice” on Twitter, so be sure to follow him (@DrFaltas) for updates in real-time. Dr. Scott Tagawa (@DrScottTagawa) is now on Twitter too and also tweeting live from the symposium. The official conference hashtag is #GU17.

Some #GU17 highlights

Day 1 – The initial session focused on active surveillance for prostate cancer, including using both imaging as well as tissue biomarkers to help select optimal patients for surveillance versus those who should undergo surgery or radiation. A subsequent session focused on prostate cancer that progresses despite therapy and the pathways of resistance that can develop. This included a discussion of prostate cancer subtypes that become independent of the androgen-receptor (hormonal) pathway, including aggressive variant and neuroendocrine prostate cancer (NEPC). Neuroendocrine prostate cancer is one of the most aggressive and treatment-resistant types of prostate cancer that most often evolves from prior hormonal therapy.

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Dr. Misha Beltran and Dr. Gerhardt Attard are two of the primary investigators for the 2016-2018 Movember Foundation-PCF Challenge Award

Dr. Gerhardt Attard at the Institute of Cancer Research in London, gave a great talk on the value of circulating tumor DNA in prostate cancer. He spoke about the collaborative grant from the Movember Foundation and the Prostate Cancer Foundation (PCF) that he, Dr. Misha Beltran and others have used to develop signature ways to confirm neuroendocrine prostate cancer with a blood test. An additional collaborative grant will allow optimization of this technology across a larger number of centers. Learn more about this prestigious Movember Foundation-PCF Challenge Award and how we’re using genomic characterization of tumors in less invasive ways in order to bring precision medicine – or narrowly tailored, personalized treatment – to more patients.

evi_taxynergy_gu-symposium_jpgDr. Evi Giannakakou explains to a crowd of physician-scientists results from our TAXYNERGY clinical trial showing additional evidence of using cancer cells circulating in the blood, also referred to as circulating tumor cells or CTCs, as a primary biomarker for chemotherapy response. This research validated prior work regarding the mechanism of action of chemotherapy in prostate cancer and demonstrates that using a simple blood draw, within one week of first chemotherapy treatment, we’re able to determine whether men with metastatic prostate cancer have a higher chance of responding. In the future, this might spare men from additional treatment (with associated side effects) with a drug that has a lower chance of working. For additional background information on this research, check out our prior in-depth blog post on the topic.

jok9106Dr. Josephine Kang, a radiation oncologist at WCM/NYP, presented a poster on Stereotactic Body Radiotherapy (SBRT), which is an emerging treatment modality with excellent control rates for low- and intermediate-risk prostate cancer. The role of SBRT for high-risk prostate cancer has not been studied as closely, but this trial showed encouraging results for those with high-risk disease. These results are very encouraging, as the treatment can be completed in 5 treatments. Additionally, this data longitudinally followed men treated with this modality for 7 years, and it appears to be a safe and effective treatment for high-risk prostate carcinoma. SBRT may be a good treatment alternative particularly for patients unable to undergo hormonal therapy (androgen receptor therapy/ADT) or unwilling to receive standard 8-9 week radiation therapy. More research is ongoing. Learn more about our open clinical trial using this modality. Another study will soon be opening.

In the oral abstract session, data was presented from a cooperative group trial that the older chemotherapy drug mitoxantrone should not be used immediately following surgery. Assays from biopsy material can separate different classes of prostate cancer with different risk for inferior outcomes. Blood biomarkers utilizing circulating tumor cells appear to be prognostic and potentially predictive of response to certain drugs. We are currently participating in a study to validate this data across multiple institutions and technology platforms.

In the keynote lecture, Dr. Charles Drake who recently joined the NYP family at Columbia discussed the current status and future directions of immunotherapy for prostate cancer.

Stay tuned for additional updates throughout the symposium!

8 Tips for a Healthy Mouth During Cancer Treatment

Four different colored toothbrushes in toothbrush holder.We grow up learning certain truths regarding the need to brush our teeth at least twice a day and visit the dentist on a regular basis, but during cancer treatment, our mouth needs can change.

Cancer treatment is designed to fight the cancer cells in your body, but in doing so can have a wide range of side effects. One of the main side effects of chemotherapy, the standard treatment for prostate, bladder, and testicular cancers, is changes that occur in the mouth. Chemotherapy can lower white blood cell, platelet, and red blood cell counts throughout the body, so patients are at increased risk for infections. Gum diseases, dental abscesses, and cavities are all infections that are prone to worsen during treatment.

While killing cancer cells, cancer treatment can also harm normal cells, such as the cells in the mouth. This can cause problems with your mucosa and gums (the soft lining of your mouth) and the glands that make saliva. Additionally, both chemotherapy and radiation treatment can cause mucositis, a side effect that involves an inflammation of the lining of the mouth and can lead to red, painful sores.

Here are 8 tips to maintain good oral hygiene and ease mouth pain during cancer treatment:

  1. Visit your dentist early in treatment. See if your doctor can identify potential sources of dental infection or irritation prior to starting chemotherapy. Get any dental cleanings, teeth extractions, and fillings at least 2 weeks before starting treatment. This will help to prevent mouth problems so that you can get the most out of your cancer treatment.
  2. Brush your teeth. During treatment, do not neglect brushing your teeth at least 3 times a day. Use a brush with soft bristles and be gentle on your gums. Consider using a toothpaste designed for sensitive teeth and gums, and make sure that your toothpaste contains fluoride to prevent cavities and tooth demineralization, especially if you have a dry mouth. If you wear dentures, make sure that they are adjusted properly with a comfortable fit. Brush and rinse your dentures after meals and do not wear them while sleeping.
  3. Keep your gums healthy. Floss regularly as long as your platelet count is above 20,000. This is to minimize inflammation of the soft tissues in your mouth which can lead to dental disease, bleeding and infection if your blood counts are low. If possible, start a good flossing routine prior to starting chemotherapy so that your gums are healthy going into treatment.
  4. Pay attention to what you eat. What you put in your mouth matters, and not just in terms of maintaining a balanced diet during treatment. Read package labels to find out what’s in the foods you’re eating, as this will help determine what may irritate your mouth. Hot and spicy sauces can increase pain and sensitivity, especially if you have sores in your mouth. Caffeinated beverages and alcohol can increase mouth dryness, and vinegars, citrus and tomato juices have a lot of acidity which can also irritate the mouth. Be in tune with which foods might be triggers, and if eating out, ask whether sauces and dressings can be omitted or served on the side.
  5. Modify your diet as needed. If your mouth is sore, eating soft, bland, room-temperature food may help. If your mouth is dry, you can add extra moisture to foods in the form of sauces, oils, milk or broth to aid in swallowing. Foods such as eggs, yogurt, cottage cheese, soups, cooked vegetables, pudding, milkshakes and smoothies can often be tolerated when your mouth is sore or dry. If you experience taste changes, experiment with different foods at different temperatures.
  6. Cut down on sugar. Avoid foods that have a lot of sugar because your teeth are more vulnerable to infections and cavities during cancer treatment. Beware of sugar content in beverages such as soda, juice, coffee, tea and sports drinks.
  7. Rinse daily with alcohol-free mouthwash. Many types of mouthwash wash contain alcohol, which can burn your mouth and contribute to oral dryness. Keep your mouth moist with an alcohol-free mouthwash. If you suffer from dry mouth, suck on sugar-free lozenges to stimulate saliva flow. Keep your lips moist with a natural lipbalm containing bees-wax or lanolin to prevent chapping or cracking. Do not use petroleum based lip balms as these can contribute to lip dryness.
  8. Know when to speak up. Be sure to reach out to your healthcare team and dentist if you’re experiencing any of the following: Swelling or pain in the mouth or jaw, trouble swallowing, mouth ulcerations that do not heal within one week, white patches in the mouth, a burning mouth sensation, or severe oral dryness.

At Weill Cornell Medicine and NewYork-Presbyterian, we provide supportive oral care before, during and after cancer treatment. To learn more about the services we offer, click here. To make an appointment with a dentist at our center who specializing in treating cancer patients, please call Dr. Heidi Hansen at 212-746-5115.

For additional information about oral care during cancer therapy, visit the below links:
  • NCI: https://www.cancer.gov/about-cancer/treatment/side-effects/mouth-throat
  • American Dental Association: http://www.mouthhealthy.org/en/az-topics/c/cancer-dental-health
  • American Academy of Oral Medicine: Information on Dry Mouth, Information on Mucositis
  • NIH (oral mucositis): https://medlineplus.gov/ency/patientinstructions/000047.htm

Special thanks to Heidi Hansen, DMD for her contributions to this article.

Is Chemo The Best Bladder Cancer Treatment For All?

DR. SCOTT TAGAWA AND DR. BISHOY FALTAS

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The bladder is a muscular organ made up of several layers of cells. This image outlines the bladder, ureters and surrounding vessels.

State-of-the-art cancer care continues to evolve due to advances in all aspects of patient care – including diagnosis, and personalized treatment and management. By incorporating novel diagnostics, systemic therapies, molecular targeted therapies, immunotherapies, and other biotechnological strategies into treatment paradigms, patient outcomes continue to improve along the cancer continuum.

For patients with bladder cancer and other urothelial cancers (cancers of the bladder, renal pelvis and ureter), cisplatin-based chemotherapy remains the standard of care. This is based on decades of research through a series of randomized clinical trials showing that chemotherapy regimens containing cisplatin consistently lead to the best overall survival rates. Importantly, some patients with metastatic urothelial cancer who are treated with cisplatin-based regimens are cured.

However, cisplatin is hard on not just the cancer cells, but the body overall. As a result, not all patients are “fit” for cisplatin. There are standard criteria that are used to define patients for whom cisplatin is not a viable treatment option. These include kidney (renal) function as measured by a blood test and sometimes urine tests, performance status (a measure of how physically functional patients are), hearing loss, nerve damage (neuropathy/numbness), and heart failure. Some of the time, there may be trade-offs. For instance, some patients would trade off the risk of needing a hearing aid for a higher chance of tumor shrinkage (or even cure).

While it is well-known among physicians that not all bladder cancer patients are candidates for this treatment option, questions linger regarding what the best treatment option should be for these patients. To get to the bottom of this question, we reviewed the scientific evidence and Dr. Scott Tagawa recently presented our findings to a large group at the 34th annual Chemotherapy Foundation Symposium (CFS). This conference brought together over 2,000 cancer care clinicians across a multidisciplinary spectrum to provide updates on the most cutting-edge new agents, ongoing clinical trials and emerging developments in cancer treatment and diagnosis.

What did the science show?

According to recent data presented at the 2016 European Society of Medical Oncology (ESMO) meeting, the most common alternative treatment regimen for patients who are well enough to tolerate chemotherapy is the combination of carboplatin and gemcitabine chemotherapies. This was based on the review of data from 1426 patients with advanced urothelial carcinoma who were treated with chemotherapy.

Interestingly, there were some other global trends in the types of chemo prescribed. Centers that treated fewer patients with urothelial cancers were more likely to give alternative (non-cisplatin) chemotherapy to patients that did not meet any standard criteria for being unfit. The most common reason for being deemed unfit for cisplatin was the patient’s current level of kidney function. Unfortunately, data showed that patients who were fit for cisplatin, but received alternative chemotherapy lived much shorter than those who received cisplatin, and none of those patients in the study were alive at the 5-year mark.

One setting where cisplatin-based chemotherapy is very important is in the pre-operative setting where the goal is cure rather than just prolongation of life by months to years. Physicians should be aware of some “tricks of the trade” to optimize kidney function and other parameters to maximize the chance for cisplatin administration and cure. For patients, it’s important to consider at least getting a consultation at a center of excellence before making a treatment decision.

We also recently wrote an editorial in The Lancet outlining the value of immunotherapy for patients with advanced urothelial cancers who are unfit for cisplatin, and in particular checkpoint inhibitor immunotherapy. While not currently FDA-approved for this indication, a study using atezolizumab (Tecentriq) was published in this prestigious journal with a second supportive study utilizing pembrolizumab (Keytruda) presented at the ESMO meeting in October. Both studies used monoclonal antibodies that enable the immune system to become activated and fight cancer, and both demonstrated substantial responses in a subset of patients. Studies of the tumor and surrounding tissue testing for PDL1 expression are able to predict those with a higher likelihood of response, but even those with “negative” testing can respond. Tests of tumor genomics are also able to group tumors into those with a higher likelihood of response, but again, even those in the lower immune responding group can have a long-term response to immune treatment. Ongoing studies are needed to help predict response in a more powerful manner. One issue that we’ve recently examined is the difference in tumor genomics before and after chemotherapy highlighted by Dr. Faltas’ high-impact publication on the clonal evolution of urothelial cancer. Among other things, this highlights the importance of obtaining recent tissue from metastatic sites to gain the most accurate understanding of an individual patient’s tumor biology.

In summary, it is important for physicians to recognize when a patient may or may not safely receive certain chemotherapy regimens, such as cisplatin combinations in the case of urothelial carcinoma. In addition, research is ongoing for patients that are unfit for certain types of chemotherapy to prove whether or not immunotherapy should be used in patients who have not yet received chemotherapy. Several immunotherapy drugs are currently being tested in randomized clinical trials and these include patients that are unfit for cisplatin. Additionally, other drugs such as antibody-drug conjugates or monoclonal antibodies have shown promising activity in patients with advanced urothelial carcinoma, and these studies included patients unfit for cisplatin.