cáncer de vejiga avanzado: presente y futuro€¦ · cáncer de vejiga avanzado: presente y...

Daniel Castellano

Oncología Médica. Unidad de Tumores GenitoUrinariosHospital Universitario 12 de Octubre

I + 12 Research Institute@H120_GUCancer

@cdanicas

Cáncer de Vejiga avanzado: presente y futuro

Concepto de paciente ineligible a tratamiento basado en cisplatino

50% de pacientes 15-20% de pacientes

Durable Responses With Cisplatin-Based but not Carboplatin CT in advanced UC

Cisplatin Eligible Cisplatin Ineligible

Gemcitabine + Cisplatin[1,2]

ORR: 49%CR: 12%Median OS: 14.0 mos

Dose Dense MVAC[3]


Gemcitabine + Carboplatin[4]


1. von der Maase H, et al. J Clin Oncol. 2005;23:4602-4608. 2. von der Maase H, et al. J Clin Oncol. 2000;18:3068-3077. 3. Sternberg CN, et al. Eur J Cancer. 2006;42:50-54. 4. De Santis M, et al. J Clin Oncol. 2012;30:191-199.

Prop

ortio

n Su

rviv

ing 1.0

0.80.60.40.2

00 12 24 36 48 60 72 84

MosPatients at Risk, n

203202

118125

5062

3640

3034

2329

79

01

GCMVAC

GC: median 14.0 mos (12.3-15.5 mos)MVAC: median 15.2 mos (13.2-17.3 mos)HR: 1.09 (0.88-1.34)Log-rank P = .44, Walds P = .66

GCMVAC

10080604020

00 2 4 6 8 10 12

YrsPatients at Risk, nN

129134

3245

1529

1123

48

20

Median5 yrs, %(95% CI)

M-VACHD M-VAC

O112101

M-VACHD M-VAC

HD M-VAC15.1 mos

21.8 (14.5-21.9)

M-VAC14.9 mos

13.5 (7.4-19.6)

Log-rank P = .042HR: 0.76 (95% CI: 0.58- 0.99)

100

80

6040

200

0 1 2 3 4 5 6Yrs

Patients at Risk, nN119119

3744

1315

75

32

12

M-CAVIGC

O108110

Surv

ival

(%)

7

Log-rank test P = .64

M-CAVIGC

11

First-line randomised trials in cisplatin-based (fit) advanced urothelial carcinoma

Better patient selection, earlier diagnosis and screening, better supportive care (growth factors)

Author Treatment N RR (%) OS (months) Best arm

Loehrer MVACCDDP

126120

3912

12.58.2

MVAC > CDPP

Logothetis MVACCISCA

6555

6546

12.610.0

MVAC > CISCA

Von der Maase MVACGC

202203

4649

14.813.8

MVAC ~ GC

Sternberg HD-MVAC+ G-CSFMVAC

134129

6250

14.514.1

HD-MVAC ≥ MVAC

Bamias MVAC+ GCSF

DC + GCSF

109111

5437

14.29.3

MVAC > DC

Dreicer MVACPC

4441

3628

15.413.8

MVAC > PC

Bellmunt PCGGC

312315

57.146.4

15.712.8

PCG ~ GC

Bellmunt et al. Ann Oncol 2014;25 Suppl 3:iii40–8

Patients with poor comorbid status or impaired renal function ‘unfit’

Management of metastatic disease

PS ≤2 plus poor renal function

Carboplatin-based regimens or single-agents: taxane, gemcitabine

Cisplatin-based combination chemotherapy

(e.g. MVAC, GC, HDMVAC, PCG)

Clinical trial

Best supportive careProgression <12 months

Second-line chemotherapy1.Vinflunine2.Taxane-based3.Clinical trial

Progression >12 months1. Platinum-based rechallenge

First line• FIT → CISPLATIN-based combination• UNFIT → CARBOPLATIN-based regimen

Subsequent lines• Vinflunine• Taxane-based • Platinum rechallenge

Evolución de la terapia sistémica para cáncer urotelial

BLA, Biologics License Applicationhttp://www.accessdata.fda.gaov/scripts/cder/drugsatfda/index.cfm; http://www.ema.europa.eu/ema/1. Sternberg et al. Cancer 1989;64:2448–58; 2. McCaffrey et al. J Clin Oncol 1997;15:1853–73. von der Maase et al. J Clin Oncol 2005;23:4602–8; 4. Sternberg et al. J Clin Oncol 2001;19:2638–465. Vaughn et al. J Clin Oncol 2002;20:937–40; 6. Bellmunt et al. J Clin Oncol 2009;27:4454–617. Rosenberg et al. Lancet 2016;387:1909–20; 8. Balar et al. Lancet 2017;389:67–769. Sharma et al. Lancet Oncol 2017; doi: 10.1016/S1470-2045(17)30065-710. Bellmunt et al. N Engl J Med 2017; doi: 10.1056/NEJMoa161368311. Balar et al. J Clin Oncol 2017;35(suppl 6S):Abstract 284

FDA-Approved Checkpoint Inhibitors for UC

1. Atezolizumab [package insert]. July 2018. 2. Avelumab [package insert]. October 2017. 3. Durvalumab [package insert]. February 2018. 4. Nivolumab [package insert]. July 2018. 5. Pembrolizumab [package insert]. June 2018.

Agent Target Schedule FDA Approval Type by SettingPost-Platinum Frontline Cisplatin Ineligible

Atezolizumab[1] PD-L1 Q3W Level 1 AcceleratedAvelumab[2] PD-L1 Q2W Accelerated --Durvalumab[3] PD-L1 Q2W Accelerated --Nivolumab[4] PD-1 Q4W Accelerated --Pembrolizumab[5] PD-1 Q3W Level 1 Accelerated

Currently Approved Immunotherapy After Platinum-based Chemotherapy

Progression

KEYNOTE-045: Pembrolizumab vs Chemotherapy in Postplatinum Metastatic UC§ Randomized phase III trial

Pembrolizumab200 mg Q3W

(N = 270)

Investigator’s ChoicePaclitaxel 175 mg/m2 Q3W orDocetaxel 75 mg/m2 Q3W orVinflunine 320 mg/m2 Q3W

(N = 272)

Bellmunt J, et al. N Engl J Med. 2017;376:1015-1026.

Treated up to 24 mos or until CR, PD,

unacceptable AE, or investigator decision*†

Treated until PD, unacceptable AE, or patient withdrawal of

consent

*Select patients allowed to continue treatment beyond initial radiographic progression. †Patients who achieved CR could discontinue treatment after 24 wks and at least 2 doses after initial CR.

§ Primary endpoints: OS, PFS in overall and in PD-L1 CPS ≥ 10% populations

§ Secondary endpoints: ORR, DoR in overall and in PD-L1 CPS ≥ 10% populations; safety

Patients with metastatic or locally advanced UC after recurrence or

progression following platinum-based chemotherapy;

ECOG PS ≤ 2; evaluable tumor tissue for PD-L1 testing

(N = 542)

Data cutoff: May 19, 2017

KEYNOTE-045: Overall Survival

270 194 147 116 98 67 23272 171 109 73 58 35 13

44.4%30.3% 33.2%

19.7%

0 4 8 12 16 20 24 28 320

20

40

60

80O

S (%

)

Mos

100

de Wit, et al. ESMO 2017. Abstract LBA37_PR.

HR: 0.70 (95% CI: 0.57-0.86; P = .0003)

Pembro(n = 270)

CT(n = 272)

Median OS, mos (95% CI)

10.3 (8.0-12.3)

7.4 (6.3-8.3)

PembroCT

Patients at Risk, n

IMvigor211: Atezolizumab vs Chemotherapy for Postplatinum Advanced UC§ Open-label, 2-arm, randomized phase III trial

Atezolizumab1200 mg Q3W

Investigator’s ChoicePaclitaxel 175 mg/m2 Q3W orDocetaxel 75 mg/m2 Q3W orVinflunine 320 mg/m2 Q3W

Powles T, et al. Lancet. 2018;391:748-757.

Treated until loss of clinical benefit,

unacceptable AE, or investigator decision

Treated until RECIST v1.1 PD or unacceptable AE

§ Primary endpoints: OS

§ Secondary endpoints: ORR, PFS, safety, pharmacokinetics

Patients with metastatic or locally advanced UC after recurrence or progression following platinum-

based chemotherapy; ECOG PS 0/1; evaluable tumor

tissue for PD-L1 testing(N = 932)

Median OS, Mos (95% CI)

11.1 (8.6-15.5)10.6 (8.4-12.2)

IMvigor211: OS in PD-L1–Positive (IC2/3) Patients

Powles T, et al. Lancet. 2018;391:748-757.

AtezolizumabChemotherapy

Events/Patients, n

72/11688/118

12-Mo OS Rate, % (95% CI)

46.4 (37.3-55.6)41.2 (32.2-50.3)

Stratified HR: 0.87 (95% CI: 0.63-1.21; P = .41)

100

80

60

40

20

0

OS

(%)

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Patients at Risk, n

AtezolizumabChemotherapy

116118

112109

100100

8895

8591

8285

7782

7375

7171

6365

5861

5551

5147

4741

3932

3528

2724

2318

1915

1511

119

67

65

12

-1

--

Mos

Post Platinum: Phase II StudiesDurvalumabNivolumabAvelumab

Phase II Studies of Immune Checkpoint Inhibitors Leading to Accelerated Approval

Nivolumab[1]

Durvalumab[3]Avelumab[2]

OS

(%)

100

80

60

40

20

00 3 6 9 12 15

Patients at Risk, n(number censored)All treated patients 265 (0) 198 (3) 148 (4) 63 (71) 5 (125) 0 (130)

All treated patients (n = 265)

Median OS: 8.74 mos(95% CI: 6.05 to not reached)

100

80

60

40

20

0

OS

(%)

0 3 6 9 12 151 2 4 5 7 8 1011 1413 161718Mos Since Treatment Initiation

Patients at Risk, n 44 43 40 31 30 28 25 25 25 23 22 21 19 17 14 10 6 2 0

Median OS: 13.7 mos (95% CI: 8.5-NE)

Prob

abili

ty o

f OS

1.0

0.8

0.6

0.4

0.2

00 3 6 9 12 15 18 21 24 27

Mos From First Dose

Total

Median OS, mos (95% CI)

18.2 (8.1-NE)

12-mo OS rate, % (95% CI) 55 (44-65)

Total (n = 191)

1. Sharma P, et al. Lancet Oncol. 2017;18:312-322. 2. Apolo AB, et al. J Clin Oncol. 2017;35:2117-2124. 3. Powles T, et al. JAMA Oncol. 2017;3:e172411.

Overall population (n = 44)

Clinical outcomes according to PD-L1 status and age in the prospective international SAUL study of atezolizumab for locally

advanced or metastatic urothelial carcinoma or non-urothelial carcinoma of the urinary tract

Cora N. Sternberg1, Axel S. Merseburger2, Ernest Choy3, Daniel Castellano4, Fernando Lopez-Rios5, Nick James6, Giuseppe L. Banna7, Ugo De Giorgi8, Cristina Masini9, Aristotelis Bamias10, Xavier Garcia del Muro11, Thomas Powles12, Ignacio Duran13, Craig Gedye14, Marija Gamulin15, Friedemann Zengerling16, Lajos Geczi17, Sabine de Ducla18, Simon Fear18, Yohann Loriot19

1San Camillo and Forlanini Hospitals, Rome, Italya; 2Department of Urology, Campus Lübeck, University Hospital Schleswig-Holstein, Lübeck, Germany; 3CREATE Centre, Section of Rheumatology, Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK; 4Medical Oncology Service, Hospital Universitario 12 de Octubre, Madrid, Spain; 5Hospital Universitario HM Sanchinarro, Madrid, Spain; 6Institute of Cancer and Genomic Services, University of Birmingham, and Cancer Centre, Queen Elizabeth Hospital, Birmingham, UK;7Cannizzaro Hospital, Catania, Italy; 8Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy; 9Medical Oncology Unit, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy; 10National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece; 11Institut Catala d’Oncologia, IDIBELL, Barcelona, Spain; 12Barts Cancer Institute, Experimental Cancer Medicine Centre, Queen Mary University of London, St Bartholomew’s Hospital, London, UK; 13Hospital Universitario Virgen del Rocio, Seville, Spainb; 14Calvary Mater Newcastle, Waratah, NSW, Australia; 15University Hospital Centre ‘Zagreb’, Zagreb, Croatia; 16Department of Urology, University Hospital Ulm, Ulm, Germany; 17National Institute of Oncology, Budapest, Hungary; 18F. Hoffmann-La Roche Ltd, Basel, Switzerland; 19Department of Cancer Medicine and INSERM U981, Université Paris-Sud, Université Paris-Saclay, Gustave Roussy, Villejuif, FranceaCurrent affiliation: Weill Cornell Medicine, New York, NY, USA. bCurrent affiliation: Hospital Universitario Marques de Valdecilla. Santander, Spain

D Castellano, e-poster 2019

Figure 1. OS according to PD-L1 status

0 3 6 9 12 15 18 21Time (months)

Estim

ated

sur

viva

l (%

)

100

75

50

25

0

IC 2/3 (n=268)IC 0/1 (n=666)

OS IC 0/1 (n=666)

IC 2/3 (n=268)

No. of deaths, n (%) 388 (58) 132 (49)

Median OS, months (95% CI) 7.9 (6.8–9.1)

11.6 (8.8–18.8)

6-month OS rate, % (95% CI) 57 (53–61) 67 (61–72)12-month OS rate, % (95% CI) 38 (34–42) 48 (42–55)

Figure 2. Median OS and PFS within PD-L1 subgroups

0 2 4 6 8 10 12 14 16 18 20

IC 2/3 and 0 prior metastatic lines (n=111)

IC 0/1 and 0 prior metastatic lines (n=246)

3 prior lines (n=20)


1 prior line (n=548)


IC 2/3 IMvigor211-like (n=176)

IC 0/1 IMvigor211-like (n=427)

IC 2/3 (n=268)

IC 0/1 (n=666)

All patients (n=1004)

Median PFS Median OS

Months

Summary: PD-L1 Pathway Inhibitors as Postplatinum Therapy

Overall Response: Urothelial Carcinoma Post Platinum

Historical control with CT ~ 10%

Atezolizumab[1]

IMvigor 211 Avelumab[2] Durvalumab[3]

ENRICHEDNivolumab[4]

Checkmate 275Pembrolizumab[5]

KEYNOTE 045

70

60

50

40

30

20

10

0

13.4%

18.2%17.8% 19.6% 21.1%

Patie

nts

(%)

1. Powles T, et al. Lancet. 2018;391:748-757. 2. Apolo AB, et al. J Clin Oncol. 2017;35:2117-2124. 3. Powles T, et al. JAMA Oncol. 2017;3:e172411. 4. Sharma P, et al. Lancet Oncol. 2017;18:312-322. 5. Bellmunt J, et al. N Engl J Med. 2017;376:1015-1026.

12-Mo OS Rate: Urothelial Carcinoma Post Platinum

Historical control withCT ~ 26%

Data not mature

70

60

50

40

30

20

10

0

39.2%

54.3%55%

43.9%

80

Patie

nts

(%)

1. Powles T, et al. Lancet. 2018;391:748-757. 2. Apolo AB, et al. J Clin Oncol. 2017;35:2117-2124. 3. Powles T, et al. JAMA Oncol. 2017;3:e172411. 4. Sharma P, et al. Lancet Oncol. 2017;18:312-322. 5. Bellmunt J, et al. N Engl J Med. 2017;376:1015-1026.

Atezolizumab[1]

IMvigor 211 Avelumab[2] Durvalumab[3]

ENRICHEDNivolumab[4]

Checkmate 275Pembrolizumab[5]

KEYNOTE 045

Currently Approved Immunotherapy inPlatinum-based Chemotherapy Progression

IMvigor130—ESMO 2019 (LBA14): presented by Dr Enrique Grande http://bit.ly/2Z1bPbD

IMvigor130 study design

Arm CPlacebo + plt/gem

Arm AAtezo + plt/gem

Arm BAtezo monotherapy

• Locally advanced or mUC• No prior systemic therapy in the metastatic setting

• ECOG PS ≤ 2• 1L platinum-eligible• N = 1200• Randomised 1:1:1

Co-primary endpoints:• INV-assessed PFSa and OS (Arm A vs C) • OS (Arm B vs C, hierarchical approach)

Stratification factors:• PD-L1 IC status (IC0 vs IC1 vs IC2/3)• Bajorin risk factor score including KPS < 80% vs

≥ 80% and presence of visceral metastases (0 vs 1 vs 2 and/or patients with liver metastases)

• Investigator choice of plt/gem (cisplatin + gem or carboplatin + gem)

Key secondary endpoints:• INV-ORRa and DOR• PFSa and OS (Arm B vs C; PD-L1 IC2/3

subgroup)• Safety

a per RECIST 1.1.

http://bit.ly/2Z1bPbD


IMvigor130 baseline characteristics

a n = 359 for comparisons to atezo monotherapy arm. b Per Galsky criteria per protocol, excluding New York Heart Association functional classification. c Of the patients considered cisplatin eligible at study entry, 52% received carboplatin, while 10% of patients who were cisplatin ineligible received cisplatin.

CharacteristicAtezo + plt/gem

(n = 451)Placebo + plt/gem

(n = 400)aAtezo

(n = 362)Median age (range), y 69 (31-87) 67 (33-89) 67 (36-87)ECOG PS, n (%)

0 182 (40) 173 (43) 157 (43)1 209 (46) 187 (47) 174 (48)2 60 (13) 40 (10) 31 (9)

Bajorin risk factor score, n (%)0 176 (39) 162 (41) 151 (42)1 169 (37) 149 (37) 134 (37)2 and/or liver mets 106 (24) 89 (22) 77 (21)

PD-L1 status on IC, n (%)IC2/3 108 (24) 91 (23) 88 (24)IC1 195 (43) 179 (45) 160 (44)IC0 148 (33) 130 (33) 114 (31)

Cisplatin ineligibilityb 204 (45) 140 (35) 107 (30)Renal impairment 113 (25) 94 (24) 65 (18)

Investigator choice of chemotherapyc

Carboplatin 314 (70) 264 (66) 227 (63)Cisplatin 137 (30) 136 (34) 135 (37)



Final PFS: ITT (Arm A vs Arm C)

NE, not estimable. Data cutoff 31 May 2019; median survival follow-up 11.8 months (all patients).

1009080

7060504030

2010

0

PFS

(%)

0 3 6 9 12 15 18 21 24 27 30 33

MonthsNo. at Risk

6.3 mo(6.2, 7.0)

8.2 mo(6.5, 8.3)

Atezo + plt/gem 451 345 282 160 111 74 42 22 10 4 2 NEPlacebo + plt/gem 400 317 246 116 73 40 18 11 4 NE NE NE


(n = 451)


(n = 400)PFS events, n (%) 334 (74) 326 (82)Stratified HR (95% CI)

0.82 (0.70, 0.96)P = 0.007 (one-sided)



No. at Risk

Interim OS: ITT (Arm A vs Arm C)

Data cutoff 31 May 2019; median survival follow-up 11.8 months (all patients). a 5% of patients from Arm A and 20% of patients from Arm C received non-protocol immunotherapy. b Did not cross the interim efficacy boundary of 0.007 per the O’Brien-Fleming alpha spending function.

1009080

7060504030

2010

0

OS

(%)

0 3 6 9 12 15 18 21 24 27 30 33

Months

13.4 mo(12.0, 15.2)

16.0 mo(13.9, 18.9)

Atezo + plt/gem 451 408 360 301 229 163 117 72 36 16 3 NEPlacebo + plt/gem 400 359 308 255 182 123 79 49 25 8 NE NE


(n = 451)


(n = 400)OS eventsa, n (%) 235 (52) 228 (57)Stratified HR (95% CI)

0.83 (0.69, 1.00)P = 0.027 (one-sided)b



CharacteristicPatients

(n)

Arm A mOS, mo(n = 451)

Arm C mOS, mo(n = 400) HR (95% CI)a

All patients 851 16.0 13.4 0.83 (0.69, 1.00)

ECOG PS 0 355 22.0 18.2 0.83 (0.60, 1.15)1 396 14.2 10.8 0.78 (0.60, 1.01)2 100 7.4 9.3 0.99 (0.62, 1.57)

PD-L1 status 0 278 14.2 12.8 0.82 (0.60, 1.12)1 374 14.9 13.4 0.87 (0.66, 1.15)2/3 199 23.6 15.9 0.74 (0.49, 1.12)

Bajorin risk factor score 0 338 24.5 18.2 0.79 (0.57, 1.11)1 318 15.8 12.6 0.80 (0.60, 1.08)2 and/or liver

mets 195 9.5 9.5 0.94 (0.68, 1.31)

Investigator choice of chemo

Cisplatin 273 21.7 13.4 0.66 (0.47, 0.94)Carboplatin 578 14.2 13.4 0.91 (0.74, 1.14)

Interim OS subgroups: ITT (Arm A vs Arm C)

Arm C (Placebo + plt/gem) BetterArm A (Atezo + plt/gem) Better1.0

0,5

2,5

4,5

6,5

8,5

10,5

12,5

0,3 3

a Unstratified HR shown for all characteristics except for ‘All Patients’, where stratified HR is shown.



Interim OS for Monotherapy: ITT (Arm B vs Arm C)

Data cutoff 31 May 2019; median survival follow-up 11.8 months (all patients). a Comparison only includes patients concurrently enrolled with Arm B.

13.1 mo(11.7, 15.1)

No. at Risk

1009080

7060504030

2010

0

OS

(%)

0 3 6 9 12 15 18 21 24 27 30 33

Months

15.7 mo(13.1, 17.8)

Atezo 360 285 245 216 173 120 72 42 16 NE NE NEPlacebo + plt/gem 359 322 274 224 158 103 62 35 15 3 NE NE

Arm BAtezo

(n = 360)


(n = 359)a

OS events, n (%) 191 (53) 198 (55)Stratified HR (95% CI) 1.02 (0.83, 1.24)



Interim OS: PD-L1 status (Arm B vs Arm C)

Arm BAtezo

(n = 272)


(n = 274)OS events, n (%) 158 (58) 156 (57)Unstratified HR (95% CI) 1.07 (0.86, 1.33)

PD-L1 IC0/1

OS

(%)

Months MonthsAtezo

Placebo + plt/gem

No. at Risk272 210 175 152 124 85 48 28 11 NE NE NE274 246 212 173 116 73 41 21 10 2 NE NE

Arm BAtezo

(n = 88)


(n = 85)OS events, n (%) 33 (38) 42 (49)Stratified HR (95% CI) 0.68 (0.43, 1.08)

PD-L1 IC2/3

88 75 70 64 49 35 24 14 5 NE NE NE85 76 62 51 42 30 21 14 5 1 NE NE

Data cutoff 31 May 2019; median survival follow-up 11.8 months (all patients).

12.9 mo(11.3, 15.0)

13.5 mo(11.1, 16.4)

0 3 6 9 12 15 18 21 24 27 30 33

17.8 mo(10.0, NE)

NE(17.7, NE)

100908070605040302010

00 3 6 9 12 15 18 21 24 27 30 33



IMvigor130 conclusions

• IMvigor130 is the first immune checkpoint inhibitor study to demonstrate an improvement in PFS over standard of care in 1L mUC

• At this interim analysis, clinically meaningful improvement in OS was observed with atezolizumab + plt/gem vs placebo + plt/gem but did not cross the pre-specified interim efficacy boundary; follow-up will continue to final analysis

• OS benefit of atezolizumab monotherapy vs placebo + plt/gem was greater in PD-L1-selected patients (IC2/3) than in ITT patients, although not formally tested

• Atezolizumab + plt/gem was well tolerated, with a safety profile consistent with each individual agent

• The results from IMvigor130 support atezolizumab + plt/gem as an important new treatment option for patients with untreated mUC


Algorithm for first line/second line treatment for metastatic UC fromOctober 2019 – why did it change

Atezolizumab

Pembrolizumab

Atezolizumab

Pembrolizumab

Clinical Trial(IO combinatios,fgfr inh, parp

inh, TKIs)

Modified, T. Powles, ESMO 2018

Gem/cisplatin

+ Atezolizumab?

Bladder Cancer: Spectrum of Disease

Localized: ~ 95%

NMIBC: 70%CIS, Ta, T1

MIBC: 30%T2-T4

Urology

Metastatic: ~ 5%

RadiationOncology

MedicalOncology

The Future

-Pathologist

-Radiologist

-Biologist

-Palliative care Unit

- Pain Unit

- Internist

Multidisciplinary perspectives are critical!

@H120_GUCancer

@cdanicas

Muchas gracias !!

[email protected][email protected]

cáncer de vejiga avanzado: presente y futuro€¦ · cáncer de vejiga avanzado: presente y...

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