Dr. Bogdana Schmidt
speaker
69 appearances
1 recordings
1 series
first heard Oct 2024
last heard Oct 2024
Dr. Bogdana Schmidt’s voice in public audio — every appearance, attributed to the second.
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Hello, everyone, and welcome back to the Backtable podcast, your source for all things urology. You can find all previous episodes of our podcast on Apple Podcasts, Spotify, and at backtable.com. My name is Bogdana Schmidt, and it is my pleasure to introduce Dr. Andrea Apollo.
She's a tenured senior investigator, medical oncologist, and acting deputy chief of the Geomalignancies Branch and head of the Bladder Cancer Center at the NIH. She's led numerous GU clinical trials, including one we'll be discussing today. Dr. Apollo, welcome to the Backtable podcast. Thank you so much for having me. I really appreciate it. I'm really looking forward to this conversation.
We'll be discussing highlights specifically in the bladder cancer field presented at ESMO 2024 in beautiful Barcelona. Before we get into it, I just want to point out how alive our field is right now. The meeting had over 5,000 abstracts submitted, over 600 invited speakers, but what I found fascinating was the statistics on the number of trials going on in GU right now.
In my very young urologic oncology life, this is still incredibly impressive. There are currently 351 active trials in RCC, 188 in prostate cancer, and 929 in bladder cancer. This is unbelievable.
Absolutely. And I think that goal actually is reachable. You know, when I started even just a few years ago, I used to tell patients, look, if we're still doing the same thing in bladder cancer 10 years from now, we haven't done our jobs. And even in the last few years, we've made such interesting and promising advances that I'm really hopeful we'll get there.
So I wasn't sure the best way to organize this chat. So I think maybe we should start with the most advanced, most likely to be practice changing abstract, and then spend some time on things that are interesting and thought provoking, maybe not quite prime time.
But I definitely want to get your thoughts on where you think the field is heading and what you'll be looking forward to in future meetings. So with that in mind, let's jump into the Niagara trial presented to Dr. Tom Powell's.
So let's talk a little bit about the details of Niagara. So like you said, it's neoadjuvant cisplatin-based chemo with perioptervalumab addition. So these are patients who got dervalumab before and after.
One of the things that I thought was interesting here, and I want to see what you think about that, as you mentioned on it about cisplatin versus carboplatin, is patients were able to receive cisplatin with a creatinine clearance of down to 40%. Is that your typical practice? Are you seeing patients going to split dose at 40, or do you generally cut off patients at 50?
One other thing I wanted to highlight for this trial, and maybe we'll come back to that as well, is the patient population here. So we looked at patients that were T2 to T4, N0 and N1. So there were some node positive patients here. And of course, in the comparator arm, patients were randomized to get just GEMSYS and radical cystectomy, didn't get any adjuvant treatment.
Looking at this trial, if you were designing it today, what would you have included or tried to do differently? Knowing, obviously, this trial was enrolling when I was a fellow, so five years ago, so I know we didn't have a ton of the data that we have now.
But given the groupings, given the decisions that were made in the standard of care arms, if you were redesigning it, how would you do it differently now?
Yes, which we'll get to in a minute.
I agree. And I do want to get back to your point. I think that's a really important point of path CR as an outcome here, because that is tricky, right? We know that even from old trials, SWOG trial, Nordic, et cetera, that when we were looking at neoadjuvant chemo in this setting, there is a PT0 rate from TUR alone, meaning no neoadjuvant treatment whatsoever, in the 12% to 15% range.
And neoadjuvant chemo gets you 25% to 38%. There is that variability of did you get a good TUR? Was it in a location where you could have truly resected all of it? And those factors are really hard to account for. But I think to me, when I think about these things, I think that the distant metastatic potential is what I worry about the most. Right. That's why we're giving the neoadjuvant chemo.
It's for the micrometastatic disease. It's to combat that. And so here the adjuvant stuff becomes really important because. PT zero, I don't know how meaningful of an endpoint it is long term. Right.
And I think to that point, so there were in this trial, correct me if I'm wrong, about 60 something patients, 63 patients who ended up not getting a cystectomy. So figuring out the data on those patients, I think also will be informative. What do you think about that and how that factors into how we interpret the data altogether? Yeah.
If those patients remain disease-free, right? That's the important caveat because from retrospective data, we know that patients who were T0 after neoadjuvant therapy, who didn't go on to cystectomy, have a recurrence rate of up to 50%, right, if you follow them one to two years. And so obviously that's without adjuvant treatment.
But I think that's where a lot of the future will come in is how can we treat this patient? How can we pursue Protect the bladder, certainly. I mean, if we get to a point in bladder cancer that I don't have to take out bladders, I won't cry. But I want my patients to do well.
And I think figuring out which patients are going to be able to do well with their bladders intact and how do we get them there, that'll really change the game. I mean, certainly that's what we all want. That's what I would want.
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