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AUA2017 BOSTON, MA ANNUAL MEETING HIGHLIGHTS3CME Information Continued from page 2sultant or Advisor, Scientific Study orTrial; Dendreon: Consultant or Advisor; Eli Lilly: Consultant or Advisor;Genentech: Consultant or Advisor, Scientific Study or Trial; Illumina: Investment Interest; Astellas: Scientific Studyor Trial; NCI Bladder Cancer Task Force:Leadership Position; Alliance for ClinicalTrials in Oncology: Leadership Position;Mirati: Scientific Study or Trial; Sanofi US Services: Consultant or Advisor;Agensys: Consultant or Advisor, Scientific Study or Trial; AstraZeneca: Consultant or Advisor, Meeting Participant orLecturer; Bayer: Consultant or Advisor;Bristol-Myers Squibb: Consultant or Advisor, Meeting Participant or Lecturer;EMD Serono: Consultant or Advisor;Inovio: Consultant or Advisor; Medscape:Meeting Participant or Lecturer; SeattleGenetics: Consultant or Advisor; Gritstone: Consultant or AdvisorJeff Michalski, MD, MBA, FACR,FASTROVice Chairman, Radiation OncologyWashington University Medical SchoolSt. Louis, MODisclosures: Nothing to discloseCourse #085IC: Management ofNonmuscle Invasive Bladder Cancer: Practice Solutions for Common ProblemsLearning ObjectivesAt the conclusion of this CME activity,participants should be able to: Implement the 2015 practice guidelines into the office setting Identify the best intravesical agentand duration of therapy for low,intermediate and high risk settings Identify methods to treat significanttoxicities from various intravesicaltherapies Define high risk scenarios that necessitate cystectomyFacultyCheryl T. Lee, MD, Course DirectorChair, Department of UrologyThe Ohio State UniversityColumbus, OHDisclosures: Adolor: Health Publishing;Pfizer: Scientific Study or Trial; Tengion,Inc: Consultant or Advisor, ScientificStudy or Trial; Endo Pharmaceuticals: Scientific Study or Trial; Inverness: Consultant or Advisor; Photocure: HealthPublishing; Allergan: Health Publishing,Consultant or Advisor; Archimedes: Consultant or Advisor; CVI: Consultant orAdvisor; MedEdicus: Health PublishingAshish M. Kamat, MBBS, MD,FACSProfessor of UrologyThe University of Texas MD AndersonCancer CenterHouston, TXDisclosures: Biosite: Scientific Studyor Trial; Endo Pharmaceuticals: ScientificStudy or Trial; Bioniche Therapeutics: Scientific Study or Trial; Adolor: ScientificStudy or Trial; Celgene: Scientific Studyor Trial; Tetralogic Pharmaceuticals: Consultant or Advisor; Astra-Zeneca: Scientific Study or Trial; Precision Therapeutics:Consultant or Advisor; GE Healthcare:Meeting Participant or Lecturer; TarisBiomedical: Consultant or Advisor; Archimedes, Inc.: Consultant or Advisor; Alere,Inc.: Scientific Study or Trial; FKD:Scientific Study or Trial; Photocure: Consultant or Advisor, Meeting Participantor Lecturer, Scientific Study or Trial;Sanofi: Consultant or Advisor, MeetingParticipant or Lecturer; Cubist: MeetingParticipant or Lecturer; Allergan: Meeting Participant or Lecturer; Abbott Molecular: Consultant or Advisor; Theralase:Consultant or Advisor; Telesta Therapeutics Inc. (formerly Bioniche): Consultantor Advisor; Heat Biologics: Consultantor Advisor, Scientific Study or Trial;Pacific Edge, Ltd: Meeting Participant orLecturer; Merck: Consultant or Advisor,Scientific Study or Trial; Aurasence: Consultant or Advisor; Adolor: Consultantor Advisor, Scientific Study or Trial;Spectrum Pharmaceuticals: Consultant orAdvisor; Oncogenix: Consultant or Advisor; Cepheid: Consultant or AdvisorJ. Alfred Witjes, MDProfessor, Oncological UrologyRadboud University Medical CenterNijmegen, NetherlandsDisclosures: Photocure Oslo: MeetingParticipant or Lecturer; MEL: Consultant or Advisor, Meeting Participant orLecturer; Sanofi Pasteur: Consultant orAdvisor, Meeting Participant or Lecturer; Spectrum: Consultant or Advisor, Meeting Participant or Lecturer;Taris: Consultant or Advisor, MeetingParticipant or Lecturer; Astellas: Consultant or Advisor, Meeting Participantor Lecturer; ENDO Pharmaceuticals: Consultant or Advisor, Meeting Participantor Lecturer; GE Healthcare: Consultantor Advisor, Meeting Participant or Lecturer; Ipsen: Meeting Participant or Lecturer; Theracoat: Consultant or Advisor,Scientific Study or TrialKamal S. Pohar, MDAssociate Professor of UrologyThe Ohio State UniversityColumbus, OHDisclosures: Nothing to disclosePlannersEducation CouncilManoj Monga, MD, FACSDirector, Center for Endourology &Stone DiseaseCleveland ClinicCleveland, OHDisclosures: US Endoscopy: Consultantor Advisor; Thermadex: Consultant orAdvisor; Percuvision: Consultant or Advisor; Histosonics: Consultant or Advisor;Taris Biomedical: Scientific Study or Trial;Xenolith: Scientific Study or Trial; CookUrological: Meeting Participant or Lecturer; Mission Pharmacal: Meeting Participant or Lecturer; Coloplast: Consultant or Advisor; Olympus: Consultant orAdvisor; Bard: Consultant or Advisor;Fortec: Other: Quality Assurance; Endourology Society: Leadership Position; IndianAmerican Urological Association: LeadershipPosition; Ohio Urological Society: Leadership Position; Journal of Endourology:Health Publishing; Indian Journal of Urology: Health Publishing; Brazilian Journalof Urology: Health Publishing; PracticalReviews in Urology: Health Publishing; Continued on page 4

4AUA2017 BOSTON, MA ANNUAL MEETING HIGHLIGHTSCME Information Continued from page 3CMS SCIP - Representative for AUA:Leadership PositionVictor W. Nitti, MDProfessor, Department of UrologyProfessor, Department of Obstetricsand GynecologyDirector, Female Pelvic Medicine andReconstructive SurgeryVice Chair, Department of UrologyNYC School of MedicineNew York, NYDisclosures: Astellas: Health Publishing, Scientific Study or Trial; Ethicon: Consultant or Advisor; Allergan:Health Publishing, Scientific Study orTrial; Medtronic: Consultant or Advisor;Allergan: Health Publishing, Consultant or Advisor, Meeting Participantor Lecturer, Scientific Study or Trial;Pfizer: Health Publishing, Consultantor Advisor; Coloplast: Health Publishing, Consultant or Advisor, ScientificStudy or Trial; Serenity Pharmaceuticals:Investment Interest; Coloplast: HealthPublishing, Consultant or Advisor, Scientific Study or Trial; Uroplasty: Consultant or Advisor; American MedicalSystems: Health Publishing, Consultantor Advisor, Scientific Study or Trial;Astellas: Health Publishing, Consultantor Advisor, Scientific Study or Trial;Pfizer: Consultant or Advisor; Ipsen:Consultant or Advisor; Ono: Consultant or Advisor; Theracoat: Consultantor Advisor; Pneumoflex: Consultant orAdvisor; Pfizer: Consultant or Advisor;Cook Myosite: Scientific Study or Trial;Medtronic: Scientific Study or TrialBrant Inman, MD, MSAssociate Professor, SurgeryVice Chief, UrologyDuke Cancer Institute of Duke UniversityDurham, NCDisclosures: Dendreon: Scientific Studyor Trial; Abbott Laboratories: ScientificStudy or Trial; Ferring Pharmaceuticals:Consultant or Advisor; Genentech Inc:Scientific Study or Trial; Pfizer: Other:Sponsored educational forum; CombatMedical: Consultant or Advisor, Scientific Study or Trial; FKD Therapies:Scientific Study or Trial; AstraZeneca:Consultant or Advisor; Taris Biomedical: Consultant or Advisor; AstraZeneca:Consultant or Advisor; BioCancell: Consultant or Advisor; Nucleix: ScientificStudy or TrialAcknowledgementsThe AUA Office of Education wouldlike to thank the companies who support continuing education of physicians. The AUA recognizes the following company for providing educationalgrant support:MerckAmerican Urological Association Education & Research, Inc. ensures that alleducational activities are developed andimplemented independent of the control and/or influence of any commercialinterests (ACCME: SCS1).AUA Disclosure PolicyAll persons in a position to control thecontent of an educational activity (ieactivity planners, presenters, authors)are required to disclose to the providerany relevant financial relationships withany commercial interest. The AUAmust determine if the individual’s relationships may influence the educationalcontent and resolve any conflicts ofinterest prior to the commencementof the educational activity. The intentof this disclosure is not to preventindividuals with relevant financial relationships from participating, but ratherto provide learners information withwhich they can make their own judgments.Resolution of Identified Conflictof InterestAll disclosures will be reviewed bythe program/course directors or editorsfor identification of conflicts of interest. Peer reviewers, working with theprogram directors and/or editors, willdocument the mechanism(s) for management and resolution of the conflictof interest and final approval of theactivity will be documented prior toimplementation. Any of the mechanisms below can/will be used to resolveconflict of interest: Peer review for valid, evidencebased content of all materials associated with an educational activity bythe course/program director, editor,and/or Education Content ReviewCommittee or its subgroup Limit content to evidence with norecommendations Introduction of a debate formatwith an unbiased moderator (pointcounterpoint) Inclusion of moderated panel discussion Publication of a parallel or rebuttalarticle for an article that is felt to bebiased Limit equipment representatives toproviding logistics and operationsupport only in procedural demonstrations Divestiture of the relationship byfacultyEvidence-Based ContentIt is the policy of the AUA to ensurethat the content contained in this CMEactivity is valid, fair, balanced, scientifically rigorous and free of commercialbias.Off-label or Unapproved Use ofDrugs or DevicesIt is the policy of the AUA to requirethe disclosure of all references to offlabel or unapproved uses of drugsor devices prior to the presentationof educational content. The audienceis advised that this continuing medical education activity may containreference(s) to off-label or unapproveduses of drugs or devices. Please consultthe prescribing information for full disclosure of approved uses.DisclaimerThe opinions and recommendationsexpressed by faculty, authors and otherexperts whose input is included in thisprogram are their own and do not Continued on page 5

AUA2017 BOSTON, MA ANNUAL MEETING HIGHLIGHTS5CME Information Continued from page 4necessarily represent the viewpoint ofthe AUA.Reproduction PermissionReproduction of written materialsdeveloped for this AUA course is pro-hibited without the written permissionfrom individual authors and the American Urological Association.AUA Privacy and ConfidentialityPolicyAccess the AUA Privacy and Confidentiality Policy online at .cfm.

6AUA2017 BOSTON, MA ANNUAL MEETING HIGHLIGHTSCOURSE #002ICChemotherapy and Immunotherapy Options forGenitourinary MalignanciesCostas D. Lallas, MD, FACS, Course Director; Anne E. Calvaresi, MSN, CRNP and Edouard J. Trabulsi, MD, FACS, FacultyThe new generation of management ofgenitourinary malignancies is markedby multidisciplinary care, interdisciplinary conferences and collaborativeefforts. Long gone are the days whenthese patients were treated by cliniciansoperating out of separate silos with outcomes often determined by one personmaking the majority of the decisionssurrounding care.Concurrently, urologists countrywideare facing a profound workforce shortage. Although it is conceivable thatoffice urology, including the diagnosisand behavioral or medical treatment ofstraightforward urological maladies, canbe offloaded to primary care physicians,the treatment of patients with genitourinary malignancies should never be performed far from the input of a urologiconcologist.Putting this all together, namely theemergence of multidisciplinary management of genitourinary malignancies andthe impending workforce shortage inurology, the position of the advancedpractice provider (APP) has been created, with directed formal training in urologic oncology. These physician extenders (nurse practitioners and physicianassistants) may work independently toincrease the bandwidth of a urologiconcologist, but make decisions ultimately dictated, either directly or indirectly,by the physician.The usefulness of the urologic oncology APP is clearly evident in treatingpatients with bladder cancer. The APPmust be familiar with the staging ofthis heterogeneous disease, in additionto treatments for the variety of diseasestates and their relative efficacies andpotential side effects. The APP willserve as the front line clinician, conveying much of the clinical informationand triaging, whatever surprises comethrough the door.For superficial bladder cancer APPsare responsible for administering intravesical therapies and, in addition to thescheduling of induction as well as maintenance courses of these treatments, theymust know the intricacies of each agent,especially their individual side effectsand toxicities. Depending on specificphysician or group practice patterns,APPs may be performing procedures,and it becomes their responsibility todiagnose a recurrence or raise the redflag of a potential progression. Finally,APPs should be able to discern the finerpoints of superficial bladder cancer, suchas interpreting urine cytology, determining when to order upper tract imagingor deciding when to break the routinemaintenance cystoscopy schedule.The multidisciplinary management ofmuscle invasive or metastatic bladdercancer elucidates the value of an APPwho is well trained in urologic oncology.The APP often troubleshoots difficultieswith a urinary diversion, including stomal complications and catheterization ofcontinent diversions. Additionally, theAPP can easily screen a patient with aurinary diversion for metabolic or electrolyte disorders, or infection.The fluid movement of these patientsbetween the offices of the medicaloncologist and the urologic oncologistrequires a familiarity with the systemictherapies that are being administeredto these patients. These therapies fallinto the 2 general categories of chemotherapy and immunotherapy. Thestated objectives of this course includedfamiliarizing APPs with the commonlyused agents for muscle invasive andmetastatic bladder cancer.Chemotherapy has long been usedto treat advanced urothelial malignancies, with cisplatin being the most activeagent and first chemotherapy drugapproved for the treatment of bladdercancer. One of the first combinationregimens that included cisplatin anddemonstrated good efficacy against urothelial malignancies was MVAC (methotrexate, vinblastine, doxorubicin andcisplatin). MVAC has been described inthe neoadjuvant and adjuvant settingsbut demonstrated a clear survival benefit in a landmark article comparing neoadjuvant MVAC to cystectomy alone,with ypT0 (complete response [CR])patients having the best outcomes.1MVAC can be given in a standard 3to 4 course regimen over several monthsor in an accelerated, dose dense regimen(DDMVAC) over 6 weeks. DDMVAChas demonstrated response rates superior to those of standard MVAC, witha higher CR rate and median progression-free survival but little differencein median overall survival.2 However,MVAC and DDMVAC have a relatively harsh toxicity profile, including grade3-4 hematologic toxicities and mucositis,nephrotoxicity, ototoxicity, emesis andperipheral neuropathy.Accordingly, more recently cisplatinhas been administered in combinationwith gemcitabine with similar responserates and overall survival, but bettertolerability.3 Still, one of the major limitations of cisplatin based chemotherapyregimens is that several patients may notbe considered candidates before administration because of underlying renalinsufficiency, hearing loss, neuropathyor generalized frailty. Unfortunately,alternate regimens with similar agentsdo not demonstrate similar efficacy.Most urologists and their extenders are familiar with immunotherapyfor bladder cancer. Bacillus CalmetteGuérin (BCG) was approved by theFDA (Food and Drug Administration)for the treatment of superficial bladdercancer in 1990 and it is still consideredstandard of care for noninvasive, high Continued on page 7

AUA2017 BOSTON, MA ANNUAL MEETING HIGHLIGHTS7Course #002IC Continued from page 6grade urothelial carcinoma of the bladder.4 However, despite its relative success the mechanism of BCG has notbeen fully elucidated.It is generally believed to elicit animmune response much like nativetuberculosis, for which BCG was firstcreated as a potential vaccine. In addition, the relatively muted response ofBCG in an immune deficient state suggests its foundation in immunotherapy.Although BCG is associated with easeof administration and tolerability, itcan cause particularly toxic side effects,including dysuria, fevers, arthralgia and(thankfully rarely) BCG induced sepsis,and it should never be administered inthe setting of active infection or grosshematuria.Most of the recent excitement surrounding immunotherapy and bladdercancer lies in the introduction of checkpoint inhibitors. The astounding efficacyof this class of medications against urothelial cancer prompted a well-knownand established genitourinary oncologist to state at an international meetingthat he had “not seen such dramaticresponses in my 30 years of treatingthese cancers.”The checkpoint proteins are molecules that impede immune function(namely T-cell immunity). In a normalindividual this immune regulation helpsthe body to recognize self and preventautoimmunity and immune overactivity. However, malignant cells can hijackthis mechanism and mimic the signalsreleased by healthy cells. In so doing,the immune system remains inactiveagainst the malignant cells, allowingthem to grow and proliferate unregulated.A checkpoint inhibitor takes the proverbial foot off of the brake and activates the cellular response, allowing theimmune system to attack the malignantcells. Three checkpoint targets are currently the focus of investigation, namelyPD-1 and CTLA-4 (on the T-cell), andPD-L1 (on the tumor cell). Atezolizumab is a monoclonal antibody, thefirst described PD-L1 inhibitor found tobe active in bladder cancer. It receivedaccelerated approval by the FDA forthe treatment of urothelial cancer afterfailed platinum based chemotherapy.The basis for the FDA approval wasthe phase 2 IMvigor trial, which demonstrated an objective response rateof 16% in 310 patients with platinumtreated inoperable, locally advanced ormetastatic urothelial carcinoma. Amongthose patients who responded, theseresponses tended to be durable. Grade3/4 toxicity was low as was the rateof discontinuation from the study.5 Inaddition to atezolizumab, several othercheckpoint inhibitors against PD-1,PD-L1 and CTLA-4 are under investigation.Interestingly, costimulatory proteinssuch as CD28, that activate the immuneresponse, are also being investigated.Going along with the driving analogy,these signals are like stepping on the gasto further propel the cellular responseagainst malignancies. One need onlylook at the number of checkpoint andcostimulatory proteins that have beendiscovered to imagine the true potential of immunotherapy, considering t

Vanderbilt University Medical Center Nashville, TN Disclosures: ENDO: Scientific Study . Cold Genesys, Inc: Scientific Study or Trial . 2017 AUA Annual Meeting Highlights: Bladder Cancer CME INFORMATION. 2 AUA2017 BOSTON, MA ANNUAL MEETING HIGHLIGHTS GLG: Consultant or Advisor; Bayer: Consultant or Advisor; Janssen: Consul-tant or Advisor .