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Alicia Morgans: Hi, my name is Alicia Morgans and I'm a GU Medical Oncologist at Dana-Farber Cancer Institute in Boston. I'm so thrilled to have here with me today, Doctor Athanasios Papatsoris, who is a Professor of Urology in Athens, Greece, as well as Dr. Petros Grivas, who is an Associate Professor of Medicine and a GU Medical Oncologist at the University of Washington in Seattle. Thank you both so much for being here with me today.

Athanasios Papatsoris: Thank you.

Petros Grivas: Thank you.

Alicia Morgans: Wonderful. So I wanted to speak with the two of you about several topics that are really efforts by the urologic community to bring together investigators, clinicians, and even patients and their advocates to help raise awareness in medical education around the globe. Now, the SIU is one of these efforts. This is a conference that happens, it's an international urologic conference that happens moving from city to city throughout the globe each year to try to connect those urologists around the world.

I'd love to hear from you, Athanasios, about this particular society and how it's important in bringing information, and education to urologists wherever they may be.

Athanasios Papatsoris: Yes, the SIU was founded in Paris in 1907, and actually from 1999 the headquarters are in Montreal, Canada. It has many missions and actually, it has more than 10,000 members from over 130 countries. So it's actually the third most powerful urology association after the AUA and EAU. In Greece, we were happy to host the SIU Congress in 2019, and this year, the 10th to the 14th of November, the 31st SIU Congress took place in Dubai, and actually, we as a Hellenic Urological Association, had a session and we were honored by Petros to participate in this session.

Alicia Morgans: Wonderful. And I'd love to hear from you, Petros. Can you tell me more about this particular session at the SIU this year in Dubai, and give us your perspective as a US-based medical oncologist on the importance of the Hellenic Urological Association and what it means to Greece.

Petros Grivas: Thank you so much, Alicia for having us, and I will start by saying how excited I am to be here, talking to you, Alicia and Athanasios.  And, you know, here I am wearing my Bladder Cancer Advocacy Network shirt, just to pass the message out there so the people around the world are aware of the important public health problem, which is bladder cancer, how common it is, and the impact that it has in patients lives. You know, it can cause significant morbidity and mortality, a very common cancer, and also the most expensive cancer to treat on a per-patient basis from diagnosis to death. And we work very closely, you know, with different disciplines, you know, Athanasios is a urological oncologist, very prominent and he has great expertise.

We have medical oncologists, radiation oncologists, pathologists, radiologists, and we work all together to fight bladder cancer. And I think SIU is well aligned, you know, with what we do here with UroToday, right? Education is an important mission around the world globally, right? And one of the important aspects in my mind is we try to eliminate disparities, right? And we talk about that all the time, in social media, in our clinics, in our research. And I think the practical implementation of that, you know, the important effort is important, and SIU is doing that. They try to provide education to urologists and other specialists around the globe, even in countries where the resources are much less than we have, you know, much less infrastructure when it comes to patient care, research and education.

And also, there is this effort of matching, pairing, right? Urologists, for example, from those countries with fewer means to pair with urologists in more developed countries and try to work together, because everybody can add value here and we can learn from each other. So, I have been part of SIU efforts in the last few years, and I would say it is very rewarding. You know, we have done educational workshops in different countries. I remember I was in Berlin in 2019 in an educational forum, just before the pandemic started, and of course, SIU in Athens was a great experience, as we have people from all over the world visiting beautiful Athens there. I could not go to Dubai this year, but it was great to do virtual talks. And I had the opportunity to discuss regulatory approvals with considerations from the FDA and the EMA, which may be different across different indications, and/or some different approaches, even guidelines may differ across countries.

And in the context of this wonderful SIU meeting in Dubai, we also had the Hellenic Urological Association meeting one day, and Athanasios was a big part of that and organizing that with other colleagues, and it was a very, very exciting experience. I had the opportunity to talk about smashing news in kidney cancer. And I can tell you, I just learned a lot by reviewing the literature and talking to other colleagues who are treating kidney cancer every day. And it's just amazing to see how, number one, the advances have been over the years, huge improvements also in, you know, bladder cancer, of course, and prostate cancer, no doubt. But also, how many ways we still have ahead of us, how much work we need to do to improve the cure rates, and also, again, going back to my first point, how we can work at the global level to eliminate disparities and ensure access to care and access to life-prolonging medications across the globe.

And that can impact Greece where I am from originally and also other countries around the world. So I'm very excited to be part of this effort. And as Athanasios mentioned, this has been a long lasting  society with very important goals, and it is great to be part of that.

Alicia Morgans: I can imagine it is, and very rewarding. And I wonder, Athanasios, from your perspective, how you see the Hellenic Urological Association really trying to perform research, to push educational efforts, to ensure adequate and equitable access of care for patients in Greece and elsewhere, as you try to make sure that that information for best practices is really dispersed as well. How does that work with the Hellenic Urologic Association?

Athanasios Papatsoris: Yes, we are lucky enough to have nearly 1,000 members, so this is a huge number for a country like Greece. Our population is nearly 11 million, and we are in the middle of the East and the West, and we have a very pivotal role in education and training in the Balkans. We are part of the European Association of Urology, so we follow their guidelines, but also we are interested to discuss with other countries, other continents because as a powerful urological association, we want to exchange our expertise.

And that's why we are happy to collaborate with Greek academics like Petros because we are very keen on learning from others.  And this gives me the opportunity to ask you, Petros, how easy it is to follow different guidelines, either national guidelines, or European guidelines, or NCCN guidelines, because everything changes so quickly. I'm a urological surgeon, and usually, I'm for three, four hours every day, so when I check my emails, I receive different news updates, and at the end of the day, I don't know what to follow. I don't know if you have this from your colleagues in the States?

Petros Grivas: Athanasios, that's a great point, and I agree with you about the importance, you know, of following guidelines. It's a key factor in standardizing medicine and trying to have evidence-based medicine in our daily practice and when we teach our trainees. You raise a wonderful point, you know, how different the guidelines could be, potentially, not always.  You know, there is significant alignment, I would say in most cases in the different guidelines, which is good, but there are certain circumstances, examples, maybe exceptions to the rule that there may be some discordance in the guidelines. And the first thing that comes to mind, Athanasios, is even just this past week, these last few days, we had this example of the guidelines about nivolumab, a checkpoint inhibitor for patients with muscle-invasive urothelial cancer in the adjuvant setting, after radical surgery, radical cystectomy, or radical nephroureterectomy, and how the adjuvant nivolumab data from the CheckMate 274 trial that was published recently were read out in a little bit of a different way.

In the NCCN there was overall support about the use of adjuvant nivolumab based on disease-free survival, significant benefit, and an overall recommendation about the adoption of adjuvant nivolumab in this setting based on that CheckMate 274 trial.  However, in the European guidelines, the ESMO guidelines, there was kind of a recommendation against it while we are awaiting overall survival data. And this is kind of confusing, right? Because you may have different practices between US and Europe based on those different guidelines, that tells you that the data can be interpreted in different ways.

It doesn't mean that the one is right, the other is wrong, but there may be different factors that play a role or are taken into account when the regulatory agencies think about approvals, but also how the academic investigators and colleagues think about the level of evidence, and what is enough to justify a recommendation. And I think that at the end of the day, it's great to have this dialogue, to have this discussion and interact more. I see an opportunity here, Athanasios, your point to have more international discussions, international meetings like SIU.  EMUC was a European meeting that happened in Greece recently, and you hosted that with others. These are opportunities to work together and have this dialogue, I would say more frequently and have more interaction. And again, the goal here is to optimize patient care globally.

Athanasios Papatsoris: Yes, absolutely. And we need consensus meetings. We need to sit down and discuss these differences so that we end up with a consensus. And two weeks ago we had a mock meeting. It was the first big European meeting in Athens, nearly 1,000 participants joined this meeting. It was a great opportunity to meet each other after two years, actually. So I believe that this is great and things next year will improve. The last point that I want to address is the need for MDT consensus, because I'm the chairman of the GU oncology cancer group, and many of our colleagues want to know how the MDT should ideally work because we have oncology MDT meetings in different parts of the world that either work with only the surgeon and an oncologist, they cannot find all specialties. So I want your opinion Petros regarding the MDT meetings.

Petros Grivas: Athanasios, you raise another important point, and Alicia, I would like to hear your comments too. So multidisciplinary teams, and multidisciplinary care models are very important. And I can share with you Alicia and Athanasios, at the University of Washington, we have a really wonderful opportunity to work together in a clinic every Tuesday morning with urological oncology, medical oncology, radiation oncology, pathology, and radiology in a multidisciplinary bladder cancer clinic. And we see four patients in half a day, which sounds like a low number, but actually works very well because we have a very comprehensive evaluation of those new patients who might be benefiting from multidisciplinary care. And I think they do benefit actually. We have published about a couple of years ago that about three out of five patients, 60% may have a different plan after the multidisciplinary clinic compared to before they came in to plan, just because of the expertise in their own people who do bladder cancer care every day.

And also the expert radiology and pathology review evaluation of variants, histologies, different imaging characteristics, different staging, and of course, the opportunity to enroll these patients in clinical trials that are more available in academic centers. And that's another point in how we can give access to patients to trials across the board, even community centers down the road. And this has been a great model for us and patients like it. We have high satisfaction patient scores from that clinic and because of the success of the bladder cancer multidisciplinary clinic recently at the University of Washington, Seattle Cancer Care Alliance, and Fred Hutch, we have implemented the prostate cancer multidisciplinary clinic. And in the first few months of the implementation, we see similar results, high patient satisfaction, quick problem solving, it's a one-stop-shop, right, that patients are seen in half a day.

And they leave around noon with a plan in place. And that can expedite the time to start a treatment plan and get people to therapy quicker and also enrolled in clinical trials. So the model works very well for us.  But I understand the challenges of implementing, realistically such a model in non-academic centers, right? And how can we partner with our colleagues in the community and try to work with them because they also have significant value and, create tumor boards there and even molecular tumor boards, right? How to implement precision oncology efforts, clinical trials, and also genetic counseling, right? Because germline mutations are very common and important in GU cancers and in other cancers too. So I think there's an opportunity for multidisciplinary care across the globe. I think it is kind of an unmet need for many centers. Alicia, what comments do you have on that important topic?

Alicia Morgans: Yeah. So I completely agree. I think that multidisciplinary care and multidisciplinary opinions for a given patient are very, very important, but I think it's important too, that we do acknowledge that it is not always possible or feasible even within an academic institution to have all of those physicians, seeing that group of patients in the same geographic location at the exact same time, that can be very, very difficult to overcome even in the most dedicated and most academic organizations.

But there are ways, I think we are learning through the pandemic for us to get together, even if it is remotely, perhaps over zoom showing patient pathology slides, radiology imaging, and discussing, even if we are in separate geographic locations, individual cases of patients so that we can come together as a multidisciplinary team.

So I do think that there are ways to be creative and provide that opinion, even if we can't be geographically co-localized. And it is something that we should all strive for, including things, as you said, like molecular review, genetic counseling, and all of this, even nutrition, lifestyle survivorship issues can be discussed to support patients as they go through the treatment process. And, hopefully, we, as a community can come together. Even if we're not in the same place to provide this for our patients.

Athanasios Papatsoris: We, have to be careful because maybe medical-legal issues will be raised in the future if we don't have a tumor board decision. So maybe in the future, some patients will sue doctors because the treatment was not decided after a tumor board meeting.

Alicia Morgans: I think all of this is still in flux and there are also, particularly in Europe, potential issues with data and data sharing. And of course, we always have to think about HIPAA, which is in the US to protect that health-related patient information. So lots of barriers potentially, but I think as a urologic oncologic community, we can come together and really, again, continue to think creatively about how we can really do this because it is going to be necessary for our patients, despite the barriers that we may see. So as we wrap up, I would love to hear from both of you, your final thoughts about bringing together the global community of urologic oncologists, whether it's through SIU, whether it's through the efforts of the Hellenic Urological Association, wherever we may be, what are your thought, Athanasios?

Athanasios Papatsoris: We all work for our patients. So we all have to collaborate. That is the only way to go forward and meetings like EMUC, like SIU, which will take place in Montreal next year will actually help towards this direction. And I'm very, very happy to discuss this topic with both of you.

Alicia Morgans: Well, thank you and Petros, what are your thoughts?

Petros Grivas: Well, I'm very, very excited about the future in urologic oncology, you have made strides Alicia and Athanasios, right in the last few years, as you mentioned.  We have a huge number of fantastic services too, as you mentioned correctly, Alicia, to offer to our patients, genetics, nutrition, physical therapy, rehab, psychiatry, emotional support, so on, and so forth. So I think working together to standardize approaches, trying to implement what we preach with service-based medicine, work together to eliminate healthcare disparities, I think that's an important issue. We have seen that with the COVID 19 pandemic, right, and access to vaccines worldwide. I think similar examples exist in oncology. And I think we should work together to try to work on those examples. And we have this global oncology program at Fred Hutchinson's cancer research center here, Fred Hutch. And this is really important, how we can reach out to colleagues in Africa and other parts of the world and learn together, right.

Learn from them, provide our recommendations in terms of the infrastructure, resources, how we can work together to open clinical trials, right? Because we have an issue of disparities based on race-ethnicity in clinical trial accrual. And I think it's important to acknowledge that and look at the causes and remove barriers. And I think SIU, Society of International Urology, EAU, AUA of course, and many other groups, bladder cancer focus network. I'm wearing this shirt today.  There are other groups, the National Bladder Cancer Network, the National Bladder Cancer Group, there's a Global Bladder Cancer Coalition, a World Bladder Cancer Coalition. There are so many others that I haven't mentioned that there are opportunities for global access and to education and information. And in that regard, what we are doing here with UroToday is serving the same mission. So I think keeping the channels of communication open, engaging in all the above and other organizations, and as much as we can educate, pursue research, and pursue, I would say more collaborations on a global level.  The world is huge, but at the same time, the world is small. So thank you, Alicia, for having Athanasios and me and for discussing these important issues today,

Alicia Morgans: Of course, it's truly been my pleasure. And I think as a global community, recognizing that wherever a patient is, whoever that patient is, that individual deserves the best care we can deliver. And recognizing barriers is step one. But the brilliance of the mind involved in urologic oncology can overcome those barriers. It does take time, but with each step, we can make progress. So thank you both so much for your time and for your dedication to the urologic oncology community. I appreciate it.

Athanasios Papatsoris: Thank you.

Petros Grivas: Thank you so much, Alicia and Athanasios, and congratulations on the great work you both do, and thanks to UroToday for this.