I did see an adjuvant trial that was done in the UK that looked at adjuvant cisplatin-based chemotherapy in upper tract urothelial carcinoma where they were trying to show the value of adjuvant cisplatin-based chemotherapy in upper tract carcinoma, urothelial carcinoma, post-nephroureterectomy. The good news is they seemed to achieve the clinical outcome efficacy endpoint even before their target at the interim analysis. So that was an oral presentation so I think that's something we have suspected based on retrospective data in bladder and meta-analyses in bladder cancer. But it's good to see prospective data confirming the value of cisplatin-based adjuvant chemotherapy in upper tract urothelial carcinoma. There should be impact in practice; I would say that currently the practice has been mostly to administer adjuvant cisplatin with chemotherapy in patients who have not received it in the neoadjuvant setting. So it was kind of going on already without the availability of prospective data but now we have nice prospective data to back it up.
Can you update us on the new prognostic model for patients with advanced urothelial carcinoma receiving post-platinum atezolizumab?
Yes, so this is the first time we have a new prognostic model in the setting of post-platinum atezolizumab, which is a PD-L1 inhibitor. In the past we've had a prognostic model famously known as the Bellmunt model after Joaquim Bellmunt who worked on a prognostic model to predict survival in the setting of patients getting chemotherapy like docetaxel, taxanes or vinflunine in patients who are post-platinum which consisted of three factors - anaemia, performance status and liver metastases. The more of these you had, the worse your survival was. So we tried to look at if these factors and others were significant in the PD-L1 inhibitor setting in post-platinum patients since now PD-L1, PD-1 inhibitors have kind of replaced chemotherapy as post-platinum preferred agents. So we looked at that in the atezolizumab setting. What's new is that in addition to the three factors found by Dr Bellmunt in the chemotherapy setting, performance status, liver metastases, anaemia, we now have three others including neutrophil-lymphocyte ratio - the higher the neutrophil-lymphocyte ratio the worse your survival. The second one was platelets - a high platelet count was predictive of worse survival - and the third additional factor was LDH, the higher LDH was associated with worse survival. So we have six factors, three of the old ones and three new ones, and the more of these you have you have a worse survival if you have advanced urothelial carcinoma and you're receiving atezolizumab in the post-platinum setting.
Obviously the next thing we want to do is see if this model applies across the board to other PD-1 and PD-L1 inhibitors since we now have five agents in that class approved in post-platinum patients.