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Brazilian consensus in muscle-invasive and metastatic urothelial carcinoma
Authors: Andrey Soares1,2, Icaro Carvalho2,3, Diogo Assed Bastos4, Diogo Augusto Rodrigues da Rosa5, Fernando Cotait
Maluf2,6,7, Ari Adamy Junior8, Daher Chade9, Luis Felipe Piovesan10, Allison Bruno Barcelos Borges11, Arthur
Acciolly12,13,14, Lucas Nogueira15.
Affiliations:
1. Centro Paulista de Oncologia, São Paulo, São Paulo, Brazil
2. Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
3. Instituto Abathon, São Paulo, São Paulo, Brazil
4. Hospital Sírio-Libanês, São Paulo, São Paulo, Brazil
5. Grupo Oncoclínicas Rio de Janeiro, Rio de Janeiro, Brazil
6. Beneficência Portuguesa, São Paulo, São Paulo, Brazil
7. Hospital Santa Lúcia, Brasília, Distrito Federal, Brazil
8. Hospital Santa Casa de Curitiba, Curitiba, Paraná, Brazil
9. Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da USP, São Paulo, São Paulo, Brazil
10. CEPON - Centro de Pesquisas Oncológicas, Florianópolis, Santa Catarina, Brazil
11. Hospital DF Star - Rede D’or, Brasília, Distrito Federal, Brazil
12. Sociedade Brasileira de Radioterapia, São Paulo, São Paulo, Brazil
13. Hospital Português da Bahia, Salvador, Bahia, Brazil
14. Hospital São Rafael, Salvador, Bahia, Brazil
15. Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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TREATMENT SELECTION
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1. Glomerular filtration rate limit to consider the patient eligible to receive cisplatin-based chemotherapy is:
a. 60 mL/min: 58.3%
b. 50 mL/min: 37.5%
c. 40 mL/min: 4.2%
d. Abstention
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1bis. Glomerular filtration rate limit to consider the patient eligible to receive cisplatin-based chemotherapy is:
a. 60 mL/min: 38.5%
b. 50 mL/min: 61.5%
c. 40 mL/min:0%
d. Abstention
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2. Is PS2 or higher a criterion of ineligibility for cisplatin?
a. Yes: 65.2%
b. No: 34.8%
c. Abstention
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2bis. Is PS2 or higher a criterion of ineligibility for cisplatin?
a. Yes: 80%
b. No: 20%
c. Abstention
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3. Is significant hearing loss (Grade II or higher) a criterion of cisplatin ineligibility?
a. Yes: 84.6%
b. No: 15.4%
c. Abstention
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4. Is peripheral neuropathy clinically significant (Grade II or higher) a criterion of cisplatin ineligibility?
a. Yes: 88%
b. No: 12%
c. Abstention
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5. Congestive heart failure (CHF) class III or worse is a criterion for cisplatin ineligibility?
a. Yes: 100%
b. No: 0%
c. Abstention
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6. The evaluation of PD-L1 expression is indicated:
a. In the diagnosis of muscle-invasive disease in all cases: 0%
b. In the diagnosis of metastatic disease before first-line treatment in all patients: 0%
c. In the diagnosis of metastatic disease before first-line treatment only in patients ineligible for cisplatin: 63.6%
d. After progression with first-line chemotherapy for all patients: 4.5%
e. After progression with first-line chemotherapy only in patients ineligible for cisplatin: 0%
f. I do not routinely request expression analysis of PD-L1: 31.8%
g. Abstention
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6bis. Evaluation of PD-L1 expression is indicated:
a. In the diagnosis of muscle-invasive disease in all cases: 0%
b. In the diagnosis of metastatic disease before first-line treatment in all patients: 0%
c. In the diagnosis of metastatic disease before first-line treatment only in patients ineligible for cisplatin: 92%
d. After progression with first-line chemotherapy for all patients: 4%
e. After progression with first-line chemotherapy only in patients ineligible for cisplatin: 0%
f. I do not routinely request expression analysis of PD-L1: 4%
g. Abstention
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7. The evaluation of FGFR mutations is indicated:
a. In the diagnosis of muscle-invasive disease in all cases: 0%
b. In the diagnosis of muscle-invasive disease before first-line treatment in all patients: 15.8%
c. After progression with first-line chemotherapy for all patients: 84.2%
d. The search for FGFR mutations should not be routinelyperformed : 0%
e. Abstention
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8. The material for analysis of PD-L1 and FGFR can be made:
a. In the material of the first sampling (either of the initial disease or of the metastatic disease): 8.7%
b. Always prior to the use of immunotherapy: 4.3%
c. Preferably the most recent possible, however, there is no formal recommendation for a new biopsy: 87%
d. Abstention
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NEOADJUVANT AND ADJUVANT TREATMENT -MUSCLE INVASIVE
UROTHELIAL CARCINOMA
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9. In patients with localized bladder urothelial carcinoma (T2-T4a, N0) their preferred treatment is? a. Radical cystectomy followed by adjuvant chemotherapy if stage > T2N0: 11.1%
b. Multimodal therapy (maximum TUR, followed by RT + QT): 11.1%
c. Neoadjuvant chemotherapy followed by radical cystectomy: 77.8%
d. Abstention
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10. In patients with locally advanced bladder urothelial carcinoma (Tx, N+) their preferably treatment is? a. Surgery followed by adjuvant chemotherapy: 0%
b. Isolated chemotherapy: 8.1%
c. Chemotherapy followed by radical cystectomy and lymphadenectomy: 86.5%
d. Multimodal therapy (maximum TUR, followed by RT + QT): 5.4%
e. Abstention
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11. Regarding the use of neoadjuvant chemotherapy in the treatment of muscle-invasive urothelial carcinoma: a. I indicate in all patients regardless of eligibility for cisplatin: 9.1%
b. I indicate in all non-metastatic patients which are candidates for cisplatin: 48.5%
c. I indicate only in selected cases (≥T3 or T2 with vascular invasion) and candidates for cisplatin: 36.4%
d. I do not routinely indicate and I refer for adjuvant chemotherapy after surgery: 6.1%
e. Abstention
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11bis. Regarding the use of neoadjuvant chemotherapy in the treatment of muscle-invasive urothelial carcinoma: a. I indicate in all patients regardless of eligibility for cisplatin: 2.9%
b. I indicate in all non-metastatic patients which are candidates for cisplatin: 67.6%
c. I indicate only in selected cases (≥T3 or T2 with vascular invasion) and candidates for cisplatin: 29.4%
d. I do not routinely indicate and I refer for adjuvant chemotherapy after surgery: 0%
e. Abstention
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12. Regarding the use of adjuvant chemotherapy in the treatment of muscle-invasive urothelial carcinoma: a. I indicate in all patients with staging> pT2N0, independent of cisplatin eligibility: 5.9%
b. I indicate in all patients with staging> pT2N0 that are eligible for cisplatin: 70.6%
c. I indicate only in cases pN+, regardless of cisplatin eligibility: 5.9%
d. I indicate only in cases pN+ and candidates for cisplatin: 14.7%
e. I do not indicate because there is no significant benefit: 2.9%
f. Abstention
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12bis. Regarding the use of adjuvant chemotherapy in the treatment of muscle-invasive urothelial carcinoma: a. I indicate in all patients with staging> pT2N0, independent of cisplatin eligibility: 3.1%
b. I indicate in all patients with staging> pT2N0 that are eligible for cisplatin: 90.6%
c. I indicate only in cases pN+, regardless of cisplatin eligibility: 0%
d. I indicate only in cases pN+ and candidates for cisplatin: 3.1%
e. I do not indicate because there is no significant benefit: 3.1%
f. Abstention
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13. Do you recommend neoadjuvant chemotherapy in patients who will undergo bladder preservation therapy? a. Yes: 29.4%
b. No: 47.1%
c. In selected cases: 23.5%
d. Abstention
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13bis. Do you recommend neoadjuvant chemotherapy in patients who will undergo bladder preservation therapy? a. Yes: 0%
b. No: 97.3%
c. In selected cases: 2.7%
d. Abstention
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14. Do you recommend neoadjuvant chemotherapy in patients who are not candidates for cisplatin? a. Yes: 8.8%
b. No: 64.7%
c. In selected cases: 26.5%
d. Abstention
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14bis. Do you recommend neoadjuvant chemotherapy in patients who are not candidates for cisplatin? a. Yes: 6.5%
b. No: 90.3%
c. In selected cases: 3.2%
d. Abstention
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15. When you recommend neoadjuvant chemotherapy in patients who are candidates for cisplatin, you recommend:
a. M-VAC: 11.1%
b. Dose dense M-VAC: 55.6%
c. Gemcitabine and cisplatin: 29.6%
d. Paclitaxel, gemcitabine and cisplatin: 3.7%
e. Other: 0%
f. I do not recommend chemotherapy in this scenario: 0%
g. Abstention
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15bis. When you recommend neoadjuvant chemotherapy in patients who are candidates for cisplatin, you recommend:
a. M-VAC: 0%
b. Dose dense M-VAC: 62.5%
c. Gemcitabine and cisplatin: 33.3%
d. Paclitaxel, gemcitabine and cisplatin: 4.2%
e. Other: 0%
f. I do not recommend chemotherapy in this scenario: 0%
g. Abstention
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16. Which chemotherapy regimen do you recommend in preservation therapy in patients candidates for cisplatin?
a. Cisplatin: 79.2%
b. 5FU + Mitomycin C: 16.7%
c. Gemcitabine in low dose: 0%
d. Carboplatin: 0%
e. Carboplatin and Paclitaxel: 4.2%
f. Others: 0%
g. Abstention
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17. Which chemotherapy regimen do you recommend in preservation therapy in patients who are not candidates for cisplatin? a. 5FU + Mitomycin C: 37.5%
b. Gemcitabine in low dose: 41.7%
c. Carboplatin: 12.5%
d. Carboplatin and Paclitaxel: 4.2%
e. Others: 4.2%
f. Abstention
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17bis. Which chemotherapy regimen do you recommend in preservation therapy in patients who are not candidates for cisplatin? a. 5FU + Mitomycin C: 4.8%
b. Gemcitabine in low dose: 85.7%
c. Carboplatin: 9.5%
d. Carboplatin and Paclitaxel: 0%
e. Others: 0%
f. Abstention
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18. In patients with localized / locally advanced urothelial bladder carcinoma, who received neoadjuvant chemotherapy with a cisplatin-based regimen and presented unsatisfactory pathologic response, I recommend: a. Follow-up: 91.7%
b. Adjuvant chemotherapy with the same regimen used in neoadjuvant: 0%
c. Adjuvant chemotherapy with a different regimen from neoadjuvant, based on cisplatin: 4.2%
d. Adjuvant chemotherapy with different scheme from neoadjuvant, without platinum: 4.2%
e. Abstention
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19. In patients with localized / locally advanced bladder urothelial carcinoma (pT3-4, pN+), eligible for cisplatin who did not receive neoadjuvant chemotherapy, I recommend adjuvant chemotherapy with: a. M-VAC: 0%
b. Dose dense M-VAC: 32%
c. Gemcitabine and cisplatin: 56%
d. Gemcitabine and cisplatin dose dense: 0%
e. Paclitaxel, gemcitabine and cisplatin: 12%
f. Other: 0%
g. Abstention
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19bis. In patients with localized / locally advanced bladder urothelial carcinoma (pT3-4, pN+), eligible for cisplatin who did not receive neoadjuvant chemotherapy, I recommend adjuvant chemotherapy with: a. M-VAC: 0%
b. Dose dense M-VAC: 28%
c. Gemcitabine and cisplatin: 60%
d. Gemcitabine and cisplatin dose dense: 4.0%
e. Paclitaxel, gemcitabine and cisplatin: 8.0%
f. Other: 0%
g. Abstention
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20. In patients with localized / locally advanced urothelial bladder carcinoma (pT3-4, pN+) ineligible for cisplatin who have not received neoadjuvant chemotherapy, I recommend adjuvant chemotherapy with: a. Carboplatin and Gemcitabine: 85.7%
b. Carboplatin, Paclitaxel, Gemcitabine: 7.1%
c. Carboplatin, Methotrexate and Vinblastine: 0%
d. Immunotherapy with Pembrolizumab or Atezolizumab: 7.1%
e. Gemcitabine, Paclitaxel and Adriamycin: 0%
f. Other: 0%
g. Abstention
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21. In patients with locally advanced urothelial upper tract carcinoma, when I recommend perioperative treatment, I indicate: a. Neoadjuvant chemotherapy: 45.2%
b. Adjuvant chemotherapy: 51.6%
c. Adjuvant radiotherapy: 0%
d. I never indicate peri-operative therapy in upper tract tumors: 3.2%
e. Abstention
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21bis. In patients with locally advanced urothelial upper tract carcinoma, when I recommend perioperative treatment, I indicate: a. Neoadjuvant chemotherapy: 32.1%
b. Adjuvant chemotherapy: 67.9%
c. Adjuvant radiotherapy: 0%
d. I never indicate peri-operative therapy in upper tract tumors: 0%
e. Abstention
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22. Do you recommend neoadjuvant chemotherapy in patients with upper tract tumors not candidate for cisplatin? a. Yes: 8.8%
b. No: 64.7%
c. In selected cases: 26.5%
d. Abstention
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22bis. Do you recommend neoadjuvant chemotherapy in patients with upper tract tumors not candidate for cisplatin? a. Yes: 7.1%
b. No: 89.3%
c. In selected cases: 3.6%
d. Abstention
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23. In patients with urothelial upper tract carcinoma, eligible for cisplatin that I indicate neoadjuvant chemotherapy, I recommend: a. M-VAC: 4.3%
b. Dose dense M-VAC: 39.1%
c. Gemcitabine and cisplatin: 47.8%
d. Gemcitabine and cisplatin dose dense: 4.3%
e. Paclitaxel, gemcitabine and cisplatin: 4.3%
f. Other: 0%
g. Abstention
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23bis. In patients with urothelial upper tract carcinoma, eligible for cisplatin that I indicate neoadjuvant chemotherapy, I recommend: a. M-VAC: 5.9%
b. M-VAC dose dense: 41.2%
c. Gemcitabine and cisplatin: 52.9%
d. Gemcitabine and cisplatin dose dense: 0%
e. Paclitaxel, gemcitabine and cisplatin: 0%
f. Other: 0%
g. Abstention
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24. Do you recommend adjuvant chemotherapy in patients with upper tract tumors not eligible for cisplatin?
a. Yes: 69.6%
b. No: 21.7%
c. In selected cases: 8.7%
d. Abstention
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24bis. Do you recommend adjuvant chemotherapy in patients with upper tract tumors not eligible for cisplatin?
a. Yes: 78.9%
b. No: 21.1%
c. In selected cases: 0%
d. Abstention
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25. In patients with upper tract urothelial carcinoma eligible for cisplatin, who I indicate adjuvant chemotherapy, I recommend: a. M-VAC: 4.0%
b. Dose dense M-VAC: 16%
c. Gemcitabine and cisplatin: 76%
d. Gemcitabine and cisplatin dose dense: 4.0%
e. Paclitaxel, gemcitabine and cisplatin: 0%
f. Other: 0%
g. Abstention
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26. In patients with upper tract urothelial carcinoma, who I indicate adjuvant chemotherapy and are not candidates for cisplatin, I recommend:
a. Carboplatin and Gemcitabine: 100%
b. Carboplatin, Paclitaxel, Gemcitabine: 0%
c. Carboplatin, Methotrexate and Vinblastine: 0%
d. Gemcitabine, Paclitaxel and Adriamycin: 0%
e. Immunotherapy with Pembrolizumab or Atezolizumab; 0%
f. Gemcitabine, Paclitaxel and Adriamycin: 0%
g. Other: 0%
h. Abstention
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TREATMENT OF METASTATIC DISEASE
First-line treatment
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27. Which treatment option is the most recommended for patients with metastatic urothelial carcinoma in first-line, fit for cisplatin? a. Cisplatin + Gemcitabine: 64%
b. Cisplatin + Gemcitabine + Paclitaxel: 4%
c. DD M-VAC: 24%
d. M-VAC: 4%
e. Cisplatin: 4%
f. Abstention
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27bis. Which treatment option is most recommended for patients with metastatic urothelial carcinoma in first-line, fit for cisplatin? a. Cisplatin + Gemcitabine: 87.5%
b. Cisplatin + Gemcitabine + Paclitaxel: 0%
c. DD M-VAC: 12.5%
d. M-VAC: 0%
e. Cisplatin: 0%
f. Abstention
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28. Which is the most recommended treatment option for patients with metastatic urothelial carcinoma in first-line, unfit for cisplatin, without FGFR mutations and no PD-L1 analysis? a. Carboplatin + Gemcitabine: 85%
b. M-CAVI: 0%
c. Gemcitabine + Paclitaxel: 0%
d. Paclitaxel + Gemcitabine + Carboplatin: 0%
e. Gemcitabine + Oxaliplatin: 0%
f. Gemcitabine + paclitaxel + adriamycin: 0%
g. Immunotherapy: 15%
h. Other: 0%
i. Abstention
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29. Immunotherapy may be indicated in first-line in patients unfit for cisplatin: a. For all patients: 7.4%
b. Only when PD-L1 expression > 5% (Ventana-sp142) or greater than 10% (Dako-22C3), depending on the kit used: 44.4%
c. Patients not candidates for chemotherapy: 3.7%
d. Answers B and C: 40.7%
e. Never: 3.7%
f. Abstention
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29bis. Immunotherapy may be indicated in first line in patients unfit for cisplatin: a. For all patients: 4.5%
b. Only when PD-L1 expression > 5% (Ventana-sp142) or greater than 10% (Dako-22C3), depending on the kit used: 13.6%
c. Patients not candidates for chemotherapy: 4.5%
d. Answers B and C: 77.3%
e. Never: 0%
f. Abstention
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30. Which is the most recommended treatment option for patients with metastatic urothelial carcinoma in first-line, unfit for cisplatin, without FGFR mutations and PD-L1 negative (less than 5% or 10% in the recommended tests): a. Carboplatin + Gemcitabine: 87%
b. M-CAVI: 0%
c. Gemcitabine + Paclitaxel: 0%
d. Paclitaxel + Gemcitabine + Carboplatin: 0%
e. Gemcitabine + Oxaliplatin: 0%
f. Gemcitabine + paclitaxel + adriamycin: 0%
g. Immunotherapy: 4.3%
h. Other: 8.7%
i. Abstention
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31. Which is the most recommended treatment option for patients with metastatic urothelial carcinoma in first-line, unfit for cisplatin, without FGFR mutations and PD-L1 positive (greater than 5% or 10% in the recommended tests): a. Carboplatin + Gemcitabine: 19%
b. M-CAVI: 0%
c. Gemcitabine + Paclitaxel: 0%
d. Paclitaxel + Gemcitabine + Carboplatin: 0%
e. Gemcitabine + Oxaliplatin: 0%
f. Gemcitabine + paclitaxel + adriamycin: 0%
g. Immunotherapy: 81%
h. Other: 0%
i. Abstention
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32. When immunotherapy is recommended in first-line for unfit patients for cisplatin, which one do you prefer? a. Pembrolizumab: 28.6%
b. Atezolizumab: 0%
c. Pembrolizumab or Atezolizumab: 61.9%
d. Any anti-PD1 / PD-L1 agent: 9.5%
e. Abstention
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32bis. When immunotherapy is recommended in first line for unfit patients for cisplatin, which one do you prefer? a. Pembrolizumab: 31.6%
b. Atezolizumab: 5.3%
c. Pembrolizumab or Atezolizumab: 63.2%
d. Any anti-PD1 / PD-L1 agent: 0%
e. Abstention
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33. Which is the most recommended treatment option for patients with metastatic urothelial carcinoma in first-line, unfit for cisplatin, with FGFR mutations and PD-L1 negative (less than 5% or 10% in the recommended tests): a. Carboplatin + Gemcitabine: 81%
b. M-CAVI: 0%
c. Gemcitabine + Paclitaxel: 0%
d. Paclitaxel + Gemcitabine + Carboplatin: 0%
e. Gemcitabine + Oxaliplatin: 0%
f. Gemcitabine + paclitaxel + adriamycin: 0%
g. Immunotherapy: 19%
h. Other: 0%
i. Abstention
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34. Which is the most recommended treatment option for patients with metastatic urothelial carcinoma in first line, unfit for cisplatin, with FGFR mutations and PD-L1 positive (greater than 5% or 10% in the recommended tests):
a. Carboplatin + Gemcitabine: 42.9%
b. M-CAVI: 0%
c. Gemcitabine + Paclitaxel: 0%
d. Paclitaxel + Gemcitabine + Carboplatin: 0%
e. Gemcitabine + Oxaliplatin: 0%
f. Gemcitabine + paclitaxel + adriamycin: 0%
g. Immunotherapy: 57.1%
h. Other: 0%
i. Abstention
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34bis. Which is the most recommended treatment option for patients with metastatic urothelial carcinoma in first line, unfit for cisplatin, with FGFR mutations and PD-L1 positive (greater than 5% or 10% in the recommended tests):
a. Carboplatin + Gemcitabine: 87.5%
b. M-CAVI: 0%
c. Gemcitabine + Paclitaxel: 0%
d. Paclitaxel + Gemcitabine + Carboplatin: 0%
e. Gemcitabine + Oxaliplatin: 0%
f. Gemcitabine + paclitaxel + adriamycin: 0%
g. Immunotherapy: 12.5%
h. Other: 0%
i. Abstention
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TREATMENT OF METASTATIC DISEASE Second-line treatment
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35. The preferential treatment indicated for patients with disease progression following platinum-based chemotherapy, without FGFR mutation is:
a. Vinflunine: 4.8%
b. Gemcitabine: 4.8%
c. Docetaxel / Paclitaxel: 4.8%
d. Immunotherapy: 85.7%
e. Erdafitinib: 0%
f. Abstention
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36. The preferential treatment indicated for patients with disease progression following platinum-based chemotherapy, with FGFR mutation is: a. Vinflunine: 0%
b. Gemcitabine: 0%
c. Docetaxel / Paclitaxel: 0%
d. Immunotherapy: 36.8%
e. Erdafitinib: 63.2%
f. Abstention
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36bis. The preferential treatment indicated for patients with disease progression following platinum-based chemotherapy, with FGFR mutation is: a. Vinflunine: 0%
b. Gemcitabine: 5.3%
c. Docetaxel / Paclitaxel: 0%
d. Immunotherapy: 63.2%
e. Erdafitinib: 31.6%
f. Abstention
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37. Immunotherapy may be indicated for patients with disease progression following platinum-based chemotherapy: a. For all patients: 81.8%
b. Only when there is expression of PD-L1> 5% or greater than 10%, depending on the kit used: 18.2%
c. Never: 0%
d. Abstention
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38. Preferred immunotherapy for patients with disease progression following platinum-based chemotherapy: a. Pembrolizumab: 72.7%
b. Nivolumabe: 4.5%
c. Atezolizumab: 0%
d. Durvalumab: 0%
e. Any anti-PD1 / PD-L1 agent: 22.7%
f. Abstention
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38bis. Preferred immunotherapy for patients with disease progression following platinum-based chemotherapy: a. Pembrolizumab: 95.5%
b. Nivolumabe: 0%
c. Atezolizumab: 0%
d. Durvalumab: 0%
e. Any anti-PD1 / PD-L1 agent: 4.5%
f. Abstention
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39. The preferred treatment indicated for patients with disease progression following platinum-based chemotherapy and immunotherapy, without FGFR mutation is: a. Vinflunine: 45%
b. Gemcitabine: 5%
c. Docetaxel / Paclitaxel: 35%
d. Ifosfamide: 5%
e. Pemetrexate: 5%
f. Erdafitinib: 0%
g. Other 5%
h. Clinical Support Therapy: 0%
i. Abstention
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39bis. The preferred treatment indicated for patients with disease progression following platinum-based chemotherapy and immunotherapy, without FGFR mutation is: a. Vinflunine: 66.7%
b. Gemcitabine: 0%
c. Docetaxel / Paclitaxel: 26.7%
d. Ifosfamide: 0%
e. Pemetrexate: 0%
f. Edarfitinib: 0%
g. Other: 0%
h. Clinical Support Therapy: 6.7%
i. Abstention
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40. The preferred treatment indicated for patients with disease progression following platinum-based chemotherapy and immunotherapy, with FGFR mutation is: a. Vinflunine: 0%
b. Gemcitabine: 0%
c. Docetaxel / Paclitaxel: 0%
d. Ifosfamide: 0%
e. Pemetrexate: 0%
f. Erdafitinib: 95.8%
g. Other: 0%
h. Clinical Support Therapy: 4.2%
i. Abstention
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BONE THERAPY
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41. For urothelial carcinoma patients with bone metastases, you recommend therapy with bone modifying
agents (zoledronic acid, denosumab): a. For all patients: 54.5%
b. For most patients: 36.4%
c. Only in selected cases: 9.1%
d. There is no indication: 0%
e. Abstention
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41bis. For urothelial carcinoma patients with bone metastases, you recommend therapy with bone modifying
agents (zoledronic acid, denosumab): a. For all patients: 63.2%
b. For most patients: 36.8%
c. Only in selected cases: 0%
d. There is no indication: 0%
e. Abstention
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42. Among the bone modifying agents available, you have a preference for:
a. Zoledronic acid: 19.2%
b. Denosumab: 69.2%
c. No preference: 11.5%
d. Abstention
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42bis. Among the bone modifying agents available, you have a preference for:
a. Zoledronic acid: 10.5%
b. Denosumab: 89.5%
c. No preference: 0%
d. Abstention
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43. For patients taking zoledronic acid, the dose and frequency that you recommend are: a. 4mg IV every 4 weeks: 50%
b. 4mg IV every 12 weeks: 50%
c. Abstention
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43bis. For patients taking zoledronic acid, the dose and frequency that you recommend are: a. 4mg IV every 4 weeks: 95%
b. 4mg IV every 12 weeks: 5%
c. Abstention
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44. For patients taking desonumab, the dose and frequency you recommend are:
a. 120mg SC every 4 weeks: 82.6%
b. 120mg SC every 12 weeks: 17.4%
c. Abstention
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45. For urothelial carcinoma patients with bone metastases, which duration of therapy do you recommend with bone modifying agents? a. No duration predeterminate or until a significant /intolerable adverse
event: 66.7%
b. Until 24 months: 20.8%
c. Until a new bone event: 12.5%
d. Abstention
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45bis. For urothelial carcinoma patients with bone metastases, which duration of therapy do you recommend with bone modifying agents? a. No duration predeterminate or until a significant /intolerable adverse event:
42.1%
b. Until 24 months: 57.9%
c. Until a new bone event: 0%
d. Abstention
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46. For urothelial carcinoma patients with bone metastases and under therapy with bone modifying agents that have a bone event, you recommend: a. Suspend the bone modifying agent indefinitely: 4.5%
b. Treat the bony event and proceed with the bone modifying agent: 95.5%
c. Abstention
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47. For patients on treatment with bone modifying agents, you recommend calcium / vitamin D supplementation: a. For all patients: 75%
b. For most patients: 16.7%
c. Only in selected cases: 8.3%
d. There is no indication: 0%
e. Abstention
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48. For patients who have a history of dental disturbance (tooth extraction, periodontal disease or extraction, dental implants), you recommend the use of bone modifying agents:
a. For all patients: 0%
b. Only after dental evaluation/treatment: 100%
c. We do not recommend: 0%
d. Abstention
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49. For patients who, during therapy with bone modifying agents, presented osteonecrosis of the jaw, and in which this picture is solved, you recommend: a. Continue with the treatment at the usual dose: 12%
b. Continue with the treatment with lower dose: 12%
c. Continue with the treatment with less frequency: 16%
d. I do not recommend to continue treatment: 60%
e. Abstention
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49bis. For patients who, during therapy with bone modifying agents, presented osteonecrosis of the jaw, and in which this picture is solved, you recommend: a. Continue with the treatment at the usual dose 5.0%
b. Continue with the treatment with lower dose: 0%
c. Continue with the treatment with less frequency: 0%
d. I do not recommend to continue treatment 95%
e. Abstention
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50. For urothelial carcinoma patients with bone metastases that have decreased renal function, you recommend: a. Zoledronic acid (with corrected dose): 4.8%
b. Denosumab: 95.2%
c. No preference: 0%
d. I do not recommend in these cases: 0%
e. Abstention
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GENETIC COUNSELING
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51. For urothelial carcinoma patients with no risk factors history and less than 50 years of age, genetic counseling is recommended: a. For all patients: 14.3%
b. For most patients: 14.3%
c. Only in selected cases: 50%
d. We do not recommended: 21.4%
e. Abstention
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51bis. For urothelial carcinoma patients with no risk factors history and less than 50 years of age, genetic counseling is recommended: a. For all patients: 0%
b. For most patients: 8.3%
c. Only in selected cases: 87.5%
d. We do not recommended: 4.2%
e. Abstention
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52. For patients with urothelial carcinoma and personal or family history of endometrial and/or gastrointestinal tract polyps, genetic counseling is recommended: a. For all patients: 69.7%
b. For most patients: 24.2%
c. Only in selected cases: 6.1%
d. We do not recommended: 0%
e. Abstention
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52bis. For patients with urothelial carcinoma and personal or family history of endometrial and/or gastrointestinal tract polyps, genetic counseling is recommended: a. For all patients: 0%
b. For most patients: 71.4%
c. Only in selected cases: 23.8%
d. We do not recommended: 4.8%
e. Abstention
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53. For patients with urothelial carcinoma and personal or family history of endometrial cancer (especially endometrioid subtype) and/or colorectal cancer (especially mucinous subtype), genetic counseling is recommended: a. For all patients: 91.2%
b. For most patients: 5.9%
c. Only in selected cases: 2.9%
d. We do not recommended: 0%
e. Abstention
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54. For patients with urothelial carcinoma and diagnosis of Lynch Syndrome, genetic counseling is recommended for patients and their families: a. For all patients: 97.1%
b. For most patients: 2.9%
c. Only in selected cases: 0%
d. We do not recommended: 0%
e. Abstention