USANZ 2017 – Dr Maria Ribal
Maria J Ribal is Head of the Uro-Oncology Unit, Hospital Clinic, University of Barcelona.
Maria discusses the EAU guidelines for the management of muscle invasive bladder cancer. Listen to her thoughts on the role of nephrostomy for the obstructed kidney.
Talking Urology podcast transcript
USANZ 2017 Interviews – Maria Ribal
This is Talking Urology.
Joseph Ischia: I’m Talking Urology with Maria Ribal. She’s a uro-oncologist from the University of Barcelona in Spain. She’s on the board of the EAU Guidelines and is a member of the muscle-invasive bladder cancer panel. Welcome to USANZ 2017, we’re the Talking Urology booth and today I’m going to be talking urology with Maria Ribal, who is a uro-oncologist, from the University of Barcelona in Spain. Today, she gave an excellent talk on the muscle-invasive bladder cancer, the evolving guidelines. So, we just put together a bit of a highlights package. Maria, can you tell me what were the highlights of your talk from today?
Dr Maria Ribal: Thank you very much for the introduction and for inviting me in this talk. I would say the first highlight I will stress about bladder cancer is that we have not changed mortality in the last three years. So, it’s time to do the things in a different way. So, I would say the first is that we need to treat perhaps patients earlier, we need to identify the non-muscle-invasive disease at high risk of progression, and probably offer radical therapy in this moment of the disease. And once we have the muscle-invasive disease already established, there are some key points that we should keep in mind. First, is that it’s hard to believe that we can treat it only with surgery. Probably the most rational possibility is to treat it in a multimodality form using chemotherapy and surgery. So, neoadjuvant chemotherapy has demonstrated an impact in overall survival, so it’s an advantage and we need to use it.
Joseph Ischia: On that point, we have lots of MDTs in Australia where if they’ve got an obstructed kidney, they need to go straight to surgery. What’s your thoughts on that?
Dr Maria Ribal: Yeah, this is a tricky, tricky situation. It’s true that it’s hard to believe that you can do in a safety way neoadjuvant chemotherapy with an obstructive kidney, but if the patient is fit for chemotherapy you can use a nephrostomy. You can take care of your encounter starting with antibiotics, and then it’s safe to perform neoadjuvant chemotherapy in these patients.
Joseph Ischia: Okay, and did the guidelines encourage neobladders only in certain people, who are the best?
Dr Maria Ribal: We encourage neobladders because it is already related with quality of life. But we think is that those patients that are fit for being submitted to neobladder, that they are young enough, that they are fair enough, should be offered neobladder. One thing that we should avoid is not offering neobladder because we don’t know how to do it. So, if a patient deserves a neobladder, we should refer the patient to that one hospital that is able to do it. So, I think that this is a key message in this sense.
Joseph Ischia: And in a snapshot, what’s your thoughts on adjuvant chemotherapy?
Dr Maria Ribal: Well, I think that adjuvant chemotherapy, obviously, is a useful principle in those patients that you have not used neoadjuvant chemotherapy, and it has been demonstrated recently that those patients that take most advantage of using adjuvant chemotherapy are those with locally advanced disease and zero disease. So, if we have not used neoadjuvant chemotherapy, we can use adjuvant chemotherapy.
Joseph Ischia: And are you excited about these new checkpoint inhibitors that are coming for bladder cancer?
Dr Maria Ribal: I would say the word is exactly excited because I think that this is the first change in therapy in bladder cancer in the last 15 years. So, we have been on chemo and those ends our MVAC, cis-gem, and this is the first change we have already in muscle-invasive bladder cancer. So, now we know that patients that are progressing, chemotherapy could be treated with PD-L1 inhibitors, but probably we will move this therapy to the adjuvant setting, for example, we can see them in the neoadjuvant setting as well and perhaps we will see them in the non-muscle-invasive disease at high risk of progression. So, I think there’s a lot of opportunities for this therapy in the future.
Joseph Ischia: And the role of radiation as primary treatment?
Dr Maria Ribal: Yes, the role of the radiation. I see a role of the radiation in the conservative therapy. Conservative therapy should be understood with the three therapies altogether. The TURB, the radiation therapy, and chemotherapy. And this allows you to conserve the bladder in very well-selected patients.
Joseph Ischia: And your take-home message from your talk was we need to invest in bladder cancer, are we doing that?
Dr Maria Ribal: I would say not as far as we should do because bladder cancer has been considered not as in the status of prostate cancer because it’s not as prevalent as prostate cancer, and it’s true, but it’s a very important cancer, nonetheless, for cancers. So, we should invest because there are a lot of people suffering from bladder cancer, and not only muscle-invasive but non-muscle-invasive and this is a very costly disease, because it’s submitted to long life surveillance. So, there are a lot of things we should do and we can change, so definitely we need to invest on that.
Joseph Ischia: Thank you very much, Maria. It’s been an absolute pleasure having you in Australia. Thank you.
Dr Maria Ribal: Thank you very much to you for inviting me.