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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So anything else that you wanted to highlight on this? Because I think there's still quite a bit to talk about with Niagara.
Now, I agree with you. I think it's hard to ignore the data, and truly an overall survival benefit is incredibly meaningful, and it's what we've been wanting for these patients for a long time. A couple of practical questions I have in this space for you. So, obviously, there's still some nuance, but as this gets more broadly adapted,
adopted, what do you think we as surgeons need to be looking out for taking care of these patients perioperatively? I say this because that duralumab they're getting before, right, oftentimes managed by the medical oncology team. But in the acute post-op setting, we Generally, hopefully, you know, our patients do great, go home on day four and everything's smooth as butter.
But knowing that they have gotten a perioperative checkpoint, do we need to be looking for other things post-op or in the acute periop period and not ignoring it, not thinking, oh, this is just nothing?
There were a couple patients who were pushed out for surgery, though. So they delayed time cystectomy. I don't know how that'll happen in the real world.
Yeah, I absolutely agree. I think to me, that's my main takeaway is if something doesn't look absolutely routine, my first phone calls to my medical oncologist and say, could this be immune related? What do I need to send? What other studies do you want me to get? And be thoughtful about that. With the amount of patients with variant histologies on this trial, it was up to 20%.
Are you seeing this as a positive, meaning you would extend this, basically this treatment paradigm to those patients up front, or do you want more data for that specific patient population?
Practical question again, just because I have the expert here. What about plasma cytoid, high volume plasma cytoid? Are you scanning those patients differently? Are you surveilling them any differently or about the same? Those are the patients that I always worry about. What if they're progressing on treatment? What if I'm missing a resectability window?
Excellent. Well, thank you. Again, I think this is really interesting and promising data and certainly already has the potential to be practice changing as it is. And we'll just continue to learn more and more from it. Some of the questions that we'll be looking to learn from it will actually hit on discussing a few of the other studies.
So maybe we can move on to talking about your trial, talking about Ambassador.
Absolutely. And like you said earlier, you know, we already had nivolumab approved before. So that's two positive trials in this space. We didn't really talk about Invigor, the earlier Atizo trial that didn't meet its primary endpoint, which could be related to the Atizo, could be related to where the trials were structured.
But certainly, I think we have enough data now that adjuvant therapy in the post-cystectomy setting with nivolumab or pembrolizumab is here, right? So based on this, and obviously I know you have a little bias potentially because it's your data and you're familiar with it. So it's a good bias. If and when both drugs are approved and available in the clinic space, how will you choose between them?
Yeah.
Is there any patient population or anything, just knowing, obviously, cross-trial comparisons are so fraught with so many problems, but is there any patient population for whom you might say, maybe nivolumab, we have slightly better data for? Or do you feel like the dosing schedule of Pembro kind of trumps things?
Excellent. And I think you and all of our, I think, medical oncology colleagues have been using pembrolizumab for its numerous indications. So I think that the comfort level certainly is really interesting. Can you comment a little bit about upper tract disease?
We want something. We certainly all want something.
So now to just put a point on what you just made. So let's say you have a patient who refused cisplatin up front, not, you know, didn't get Niagara Protocol. Post-op, would you still be trying to engage in chemo or checkpoint if they're eligible but refused? Would you be trying to tackle that refusal for the second time or no?
From a cup now at the NIH, this may be less of a point for you guys, but let's say a patient refuses adjuvant chemo at this point. Are you able to offer them checkpoint inhibitor in lieu of it? Oh, yes, of course. Because I know that some folks will say that they can't get insurance approval for it if they're CIS eligible. But obviously, at the NIH, this is less of an issue.
And I know there are ways to get our patients what we think is in their best interest. But even with all of this immunotherapy data, When patients didn't get cisplatin up front, we're still sort of advocating for cisplatin adjuvately because that's what we have the strongest longitudinal data for. So I'm sure that space will continue to evolve. Now, you almost led me straight to the...
to the next topic, which is how are we going to figure out how not to over-treat these patients? Because you mentioned in Niagara, right, we're having patients get dervalumab up front, then chemo, then dervalumab. Now we have ambassador and checkpoint data for just adjuvant, but we also know there are probably
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