Rana McKay: Thank you for having me. It's a real pleasure.
Ashish Kamat: It's lovely to have you on, and I'm going to pick your brains a little bit on bladder cancer. I know you talk about a lot of things, but I'm going to focus a little bit on urothelial cancer. But first off, tell us a little bit more about the AUC3. It's a meeting that's relatively in its early stages. It's three years now, I guess, and you guys have had a lot of success with some good meetings. I was fortunate enough to be part of the one this year. Tell us a little bit more about how this came about.
Rana McKay: The reason why this came about is because when we look at sort of Level 1 evidence and reducing that Level 1 evidence at the clinical practice, there's a lot of gaps. There's clinical scenarios that we encounter on a day-to-day basis in our clinics, taking care of patients with kidney and urothelial cancers or urinary tract tumors, that aren't necessarily exactly spelled out in a phase three clinical trial or exactly spelled out in guideline recommendations, whether it be NCCN, AUA, and other ASCO other sort of bodies. Really, the primary objective of AUC3, or the Advanced Urologic Cancer Consensus Conference, was to convene a group of key opinion leaders across the field and multidisciplinary team members, medical oncology, urology, radiation oncology, pathology, radiology, so that we can sort of dissect out what are these gaps and vote through a modified Delphi process on what would be indicated or a consensus based off of KOL opinion and to strategize around these gaps in the field. It's really to help guide treatment selection, sequencing strategies, biomarker utilization, and management of really challenging clinical cases that aren't necessarily covered by Level 1 evidence.
Ashish Kamat: And that's what attracted me to obviously what you guys were doing and the meeting because, through the International Bladder Cancer Group, we've been sort of doing this for the last ... Gosh, we're up for our 20th year now, but we obviously focus on bladder cancer, and we focus on very specific topics each year. Specifically, metastatic disease or sequencing, but we take one topic and distill it down. And then you guys do everything, including renal and prostate. How do you select what the most important topics are when you're tackling everything? How do you go about that?
Rana McKay: We have a very clear and systematic process. We develop a scientific committee. For the 2024 or, I guess, 2025 conference, there were five bladder sections and four kidney sections covering the key topics of non-muscle-invasive, muscle-invasive, advanced disease, sequencing, and special populations. Those were the key themes that cover the breadth of management for urothelial urinary tract tumors. For each of those themes, we appoint two scientific leads to basically help develop the first iterative draft of the key kind of gaps in that specific space. It may be diagnostic. It may be therapeutic.
We sort of have thematically the themes across this space. For bladder, there were these five topics. There were a total of 10 scientific chairs. They developed the first round of questions that gets reviewed by the steering committee. Then after that review, all the scientific chairs. There was a total of 18 scientific chairs with the first meeting. Then all the scientific chairs review all the questions. Then it gets reviewed again by the scientific committee. And then all of the panelists review all the questions again. And this is not even answering the question. This is just the process of developing the right questions. We iteratively go through this. There's probably about a total of five formal reviews of the questions prior to locking in the questions. And through that process, that's how we get to, well, what are the key gaps that we want to try to distill? And there's a lot of thought that goes into what are the answer choices. The number of answer choices. If you have a question with 25 choices, by definition, you're not going to establish consensus. How do we structure the questions in a way that is going to be able to provide meaningful data to the group? The faculty members all vote on the questions before the meeting. Then we have our discussion. Full day spent on bladder covering all the themes that I discussed. And the talk titles are formalized around the key questions. And then after the meeting, after the discussion and discourse has been had, the panelists will re-vote on all of the questions. And that basically helps establish the consensus criteria. It's a very iterative process to identify the gaps or the questions that will help elicit the gaps and elicit areas of consensus and then the discussion to be had.
Ashish Kamat: I mean, it's a very robust process, for sure, as I was able to sort of experience firsthand. And I think, like you said, you have guidelines, you have publications, and then you have what happens at the patient and the bench bedside and clinical judgment. And you can't always get that from the clinical trials or the guidelines. Something like this, in some ways, is what do we actually do and recommend in practice? How do clinicians adopt this? And that's where the publication comes in, right? Because, again, we could have these sorts of meetings all the time, and you and I and the experts could discuss this, but unless you disseminate this, and then people actually are able to read this, it's of no use to the patient. First off, congratulations on the publication. And then let me ask you, what is your goal? And we'll obviously link the publication on UroToday, but how do you like to see these recommendations, guidelines, consensus statements being used by our colleagues, not just in the US but across the globe?
Rana McKay: I mean, I think the goal is to help not replace guidelines but supplement guidelines where there's gaps on exactly what to do. And the questions get very nuanced around ... I'll even give you an example. Would you offer EV/pembrolizumab to somebody with a hemoglobin A1C of greater than eight? These patients weren't included on the trial. We have patients with diabetes.
There's no guidance around that. And in actuality, when we queried the group, there was strong consensus that you absolutely would. These are patients that are actively being followed for their diabetes. They probably are familiar with checking their blood sugars, probably more so than somebody who doesn't have diabetes and then becomes hyperglycemic. Yes, it was to offer but with guardrails around management. I think these are sort of the nuances. That's just one example. But these are sort of the nuances of the practical nature of the consensus. And we a priori define what is strong consensus, defined as greater than 90% agreement with the answer choices, and then what is consensus, which is greater than or equal to 75% agreement with the answer choices. I think our hope is that we can help guide what to do. The other piece is the areas where there's a lack of consensus I think also present an opportunity from a research standpoint of there's a complete lack of consensus at this juncture. What do we need to do to help bridge the gap? How do we better strategize? Could this be something that could be answered via a clinical trial or cohort analysis or something like that?
Ashish Kamat: I mean, again, like I said, I think that's the impressive part of it because people can look to this for practical advice. I mean, they can't always just pick up the phone and call you. You're busy. But here, they could look and see, what do the experts agree on? What do they not agree on? And then they could pick and choose and then do what needs to be done. The patient voice is, again, very important, and it's really impressive that patients are included in this process. How has that affected your ability to incorporate guidelines, consensus recommendations, hearing from the patients at these meetings?
Rana McKay: There's no way to establish patient-directed, patient-centric kind of consensus without actually integrating patients. We do have patient advocates that are present during the meeting, and I think their voice is critically important. I think, especially as we talk about preferences or quality of life or where we're thinking about risk-benefit ratios and scales, a lot of that is ... It's a value judgment that, as a clinician, you can't really make. I think making sure that the patient voice is integrated, I think, is really important. I think we kick off each day with a why it matters. Why are we here? And it's driven by a talk or kind of a level-setting, kind of why it matters, discussion by our patient advocates. And I think we're grounded in that at the meeting.
Ashish Kamat: And that's a great note to end on, Rana, because, again, we do what we do ultimately to help people and help patients. And having them and their voice guiding us is really important. I know you're busy. Thank you so much for taking the time. Always a pleasure chatting with you.
Rana McKay: My pleasure. Thanks so much for having me.