Dr. Brad McGregor

We tend to prioritize systemic therapy and then reassess in those exceptional responders.

We're a little bit too chicken to just avoid any local control.

And right now we're thinking we're doing a chemo RADS approach as a consolidating approach.

To build on what Amanda said, I think one of the struggles I have when I have a patient who wants chemoradiation, I think it's always a real option, is you started out by saying stage two is a systemic disease, right?

And so I always had this concern that if I'm doing chemoradiation

is it really okay just to get like a chemosensitive dose of radiation, not that systemic chemotherapy, right?

At this muscle base, I would give them chemotherapy for systemic disease control prior to cystectomy.

And so I think as our systemic therapies are becoming so much better and available to so many more patients, I mean, even our radiation oncologists are like, well, you know, maybe start with systemic therapy and then like, let's reassess after nine to 12 weeks.

Because I always had that nagging feeling back in my mind.

Am I, by just doing weekly cysts, how much systemic control am I really going to get?

And I think that's not the way the trials are done.

I realize that, but it's always something that we talk about.

Yeah, I mean, it says in the literature, right?

So neoadjuvant cisplatin-based chemotherapy has been the standard of care.

We have the addition of drivalumab.

But even though that allowed GFR down to 40, a majority of patients still can't get cisplatin for hearing problems or heart issues.

And so this is really an unmet need, how to offer that systemic control and pair-operative setting to patients that are in allopuric cisplatin.

So this is an interesting trial.

You know, this is actually adapted over time.

Initially, they said, well, let's look at PEMBRO in the perioperative setting versus surgery.