Future of Immunotherapy for GU Malignancies Goes Beyond Oncology Department

Costas Lallas, MDD

Immunotherapy for patients with genitourinary malignancies is no longer the domain of oncologists.

As these treatments become more effective, more widely available, and better studied, providers working as part of multidisciplinary care teams also need to develop insight into these regimens, said Costas Lallas, MD.

“Due to multidisciplinary care and workforce shortages, many of our patients are being seen by advanced practice providers, making it important for everyone to understand the chemotherapy and immunotherapy regimens for genitourinary malignancies,” he said.

OncLive: Can you give an overview of your presentation?

In an interview with OncLive at the 2017 American Urological Association, Lallas, a professor at Sidney Kimmel Medical College, Thomas Jefferson University Hospital, discussed the current role of immunotherapy for patients with genitourinary cancers, the potential for immunotherapy in combination with chemotherapy, and how the rise of immunotherapy affects all providers treating patients with these malignancies.Lallas: The course was targeted toward advanced practice providers. With multidisciplinary care and interdisciplinary conferences, we are seeing these patients more and more. Some of the medications that we talked about aren't necessarily medications that we administer ourselves. However, because we are seeing these patients and we're involved in their care all the way through, this is something that we need to familiarize ourselves with, not only for efficacy but also for side effects. With the work force shortages, there are not enough urologists to see patients, so many of these patients are being seen by advanced practice providers.

What is the status of regimens combining chemotherapy and immunotherapy?

Due to multidisciplinary care and work force shortages, many of our patients are being seen by advanced practice providers making it important for everyone to understand the chemotherapy and immunotherapy regimens for genitourinary malignancies.Historically, combinations with chemotherapy has been the goal but it depends on the tumor type. In the presentation, we discussed different tumor types including prostate cancer, kidney cancer, testicular cancer, and urothelial cancer; which includes bladder cancer and upper tract urothelial cancer.

What treatments in the pipeline are generating the most excitement?

Immunotherapy is for advanced and systemic diseases, and has been used for a long time for things such as non-muscle invasive bladder cancer. In the end, we thought it was important to not only talk about the patients but the administration and the side effects from all those different treatments.The checkpoint inhibitors are generating more interest. When you look at immunotherapy, as far as the T-cell response goes, there are agents which can move the immune process ahead. There are stimulating agents, which we're looking at actively in clinical trials.

Then you have the checkpoint inhibitors, which is how the body recognizes itself. If the body recognizes something as self, it puts on the break not wanting to fight against itself, but that is how many cancer cells are able to avoid our immune system and earlier immune therapies. What the checkpoint inhibitors do is allow us to take our foot off the break. T-cells get activated, as well as the cellular response against those malignancies, which is why they're so efficacious.

Hypothetically, if you can combine something where you're stepping on the gas pedal and you're taking your foot off the break, that ramps up the immune system maximally to fight these malignancies. Those are the exciting combinations that a lot of people are talking about.

Are there any results from ongoing trials that you are particularly interested in seeing?

There is the whole idea of combining cytotoxic chemotherapy and immunotherapy. There is a lot of excitement around that, but we’re looking for durable response.At our institution, most of the trials that we’re trying to enroll are looking at castrate-resistant prostate cancer and muscle-invasive bladder cancer in the salvage setting.

What are the most pressing questions still facing immunotherapy in this space?

Another thing which is exciting to us regarding immunotherapy for bladder cancer is using the checkpoint inhibitors for superficial disease. We know that immunotherapy works in that situation because we've been using it for years. However, what we're wondering is, can we use immunotherapy or the checkpoint inhibitors in a similar type of situation to fight non-muscle invasive bladder cancer? Those are other clinical trials which we have open at our institution focusing on those malignancies. These agents are still very new. One thing that I learned at this meeting was some of the results, which we thought were exciting, have become less so as we’re following these patients further out. It’s important not to throw all your eggs into one basket in that respect.

What are the take-away messages from your presentation?

You want to make sure that you're giving the benefit that you think you should be giving. Additionally, there are cost challenges. These regimens are very expensive and can sometimes be cost-prohibitive. That's, unfortunately, a reality all of us are having to face. As these agents become more available, something is going to have to give from a cost standpoint so that they're affordable to everybody, allowing more patients to benefit from them.Cytotoxic chemotherapy and immunotherapy are not just in the realm of the medical oncologist. These are things that the urologist is going to have to become familiar with. These are patients who urologists are going to have to know something about.