ASCO 2026 GU Highlights & FDA Approvals with Drs. Brian Rini & Tom Powles (The Uromigos)

Hello and welcome to Oncology Amigos where four brothers are trying to make sense of the recent data in G. U. Malignancy space. I'm Rahul Gossein here with my brother and co-host Rohit Gossein and today we're excited to have Dr. Brian Riny and Dr. Tom Powell's two G. U. Medical oncologist and co-host of your amigos. We share any genes even the regulations stuff is really different. Tom a lot of us are glad because I think there's that fine balance here. But let's come back to this. Here we have two G. U. Medical oncologist and co-host of your amigos podcast joining us to touch on few key studies from Asco 2026 and also on recent studies that led to a few approvals just around Asco in the space. Brian and Tom thank you so much for joining us on the oncology brothers podcast. Great to be here. Tom and Brian welcome let's dive into the G. U. World. From Asco 2026 we want to touch on three studies that were discussed there which were rather practice changing and informing at least. Proteus and Teleprote 3 in prostate cancer world and then EV302 update in bladder cancer. And just around Asco we saw many drug approvals but three of them were tied to G. U. Space that would like to touch on that is Durvalumab with BCG and non muscle invasive bladder cancer space. And then Kepi was served in prostate cancer and then Pembro with Belzude fan in adjuvant setting in RCC. Let's dive into our first study from Asco which was rather a plenary session proteus study. Brian can you go through the study design and its findings. Yeah Mary Ellen Taplin presented these data it actually started out as an investigator initiated study and then morphed into the proteus design that we see this was high risk localized prostate cancer patients randomized to ADT monotherapy or apple ludemite plus ADT prior to radical prostitectomy. So there's a neo adjuvant six cycles radical prostate septomy and then an adjuvant six cycles of the same therapy their endpoint was task is free survival was the primary endpoint. And one interesting thing is that the imaging convention changed throughout the study right it was conventional imaging first and then PS made pet came online. So they rightfully integrated that into their endpoint and we can talk about how that's affected results and so what they saw was a reduction is statistically significant reduction as ratio 0.71 in event free survival. If you look at the MFS by conventional or pet imaging you see sort of a narrower has ratio 0.8 narrowing of the curves and then some of their secondary points like time to subsequent therapy were affected as well affected positively. So I think some of the commentary around this there's been a lot of Twitter noise and stuff around this study is you know ADT alone is not ever been a control arm in these studies is not the standard of care now you could postulate that a dual therapy did better than single and of course it would do better. Then no therapy there was a separate hormone versus no therapy I don't want to say arm and was a separate study that Mary Ellen mentioned that so we'll see how that turns out I think for me it's a it's a matter of is this magnitude of benefit enough there was not a survival signal not reported anyway. And so is this you know conventional imaging has been shown to be a surrogate for outcome but but PS made pet imaging has not so how clinically meaningful is this I think is where some of the commentary has been. 8 is not overwhelming is it Brian. No I mean the hazard ratios were significant but not overwhelming and I think you know frankly not surprising rate if you give patients hormones you're going to delay the recurrence of their prostate cancer by imaging. And the radiotherapy docs don't love this because they're saying well actually does this mean more patients are going to have surgery now because that's the contri it just creates noise doesn't it I think it creates controversy. And I think it's a good study but I you're right most of the objection has been from the radiotherapy docs where obviously radiation plus hormones in this disease has been a standard for for decades may be supported by multiple phase threes. Besides the noise in the controversy at the center of all this our patients and our struggle in the community settings Ryan coming back to what you said if this was to get approved who's that right patient and second bringing a radiation oncology colleagues here in our clinical settings for that patient who meets the criteria for a proteus but the patient decides for go surgery and stick with radiation are you going to extrapolate this data for that patient. Let's see it's into these patients in my practice was a medical oncologist I think both our reasonable options surgery and we've been debating surgery versus radiation for decades right now surgery has other data to incorporate hormones which it's never had before certainly on a level on evidence standpoint so it still comes down to if I'm counseling a patient you are a dish or do you want surgery I think that's the primary decision and then what are we going to do around that based on your features secondary. Tom before we close off the chapter of proteus your final thoughts here. I like the trial I don't think it's just noise I do think when you do studies and the control arm is there this is a big endeavor and the control arm causes controversy inevitably when you present the results there's going to be difficulty right and I think that's where we are here. Another bit that is difficult in prostate cancer in my opinion is that these benefits are not survival benefits they're metastasis free survival benefits and in the end overall survival survival is also really important and so when the metastasis free survival is not overwhelming that probably is not in the end going to turn out to have more people alive in the room 10 or 15 years down the line. And that's quite important of course it's important what patients are looking for patients don't want to be on systemic therapy for advanced disease that's important quality of life has a massive impact once you have advanced disease and I'm totally brought into both parts of that so I think it's one of those studies where you can look at it as a half glass half full all glass half empty. I feel like a lot of these studies are that and having that seat on the multidisciplinary weather for that surge on red on is going to be the key along with that patient shared decision making process. Okay we ought to cover here in short period of time let's move on to our next study telepro 3 looking at part inhibitors plus Ensel Udomide in MCS PC with homologous repair mutations Brian tell us operab with Ensel Udomide did improve radiographic progression free survival. But not all HR or mutations are created equal so if you could go where what did the study show and based off of this study are you going to use park inhibitors for all MCS PC HR or mutated population or keep that reserve for selective patients. So we saw the amplitude data before this and then now telepro 3 I think as to the data that early park inhibition in HR or mutant broadly speaking is beneficial. This study showed as the others did greater effect in that bracket mutant population. They included at the M in this study which also should affect which to my knowledge hadn't been shown before certainly not in a large study so I'm really comfortable in that bracket mutated patient of incorporating park inhibition early I think everybody is in the non bracket HR or I think it's a little trickier. And it's by definition smaller subsets but as we accumulate data across trials I think you know there's never going to be just a study in ATM or just a study in check to or something so I think we're starting to accumulate evidence but I think you know the study is pretty impressive you know we did a podcast with near I Jaguar wall it's really impressive data right it's pretty broad HR or it shows pretty good effects. The OS wasn't significant but trending in the right direction you know nice split of the curves overall and especially in that bracket population so and you know well tolerated side epineas notwithstanding I think the one fine the way is they didn't allow chemotherapy in this population and so that certainly should be part of at least a subset of patients who present with high volume disease. You know for us in the community settings park inhibitor is we use this for breast cancer very cancer pancreatic cancer and of course here in prostate cancer these medications are not benign we have to worry about one medicine and fatigue but we all are very comfortable with that bracket mutated or probably too mutated Tom your thoughts here in non bracket mutated subset. Well firstly I think Brian's doing a beautiful job presenting these studies I actually honestly I prefer this study to the previous trial I actually thought this was more for me I was more impactful and the reason why is I've been pretty honestly I've been fairly skeptical about park inhibition you know it's long periods of therapy it's not without toxicity in some of the C.R. PC trials they've gone against an object. They've gone against an R.P. switch and you know also lots of bits and you know anyway the bottom line is these data also particularly presenting in that non-RACA HR are population sometimes previous trials have just put the the whole you know HR are included the bracket population so they show the same pop they show the winning population twice I thought it was clear activity in bracket on HR we've not seen that before so much. I personally feel although cross trial comparisons are different and Brian's right there were issues around chemotherapy in the study I think this is the most compact most compelling data that we've seen in for park inhibition in early disease so I was I was I was impressed. I've to agree that this is the first time we're seeing that non-RACA patients do so while with these park inhibitors while we're on prostate cancer can we also touch on the recent approval of capyverser tip this is based off capital to eight one study looking at metastatic castration sensitive prostate cancer with p 10 loss Brian given that time so impressed by how you're presenting these studies can you take over this one as well the study find things and what led to the approval of cancer. happy with assertive here in prostate cancer. - Yeah, so this, as you said, to AKT inhibitor, there've been other studies of AKT inhibitors that haven't really hit home. And so this was hormone sensitive disease, over 1,000 patients, every pred ADT in both arms, you know, with or without a bit of assertive. The patients had to have, I believe it was 90% cut off for IHC standing to show P10 deficiency and they looked at RPFS. And what they showed was, in my opinion, a marginal advantage in RPFS, if you pull up that curve, it was, has ratio was 0.81, upper end of the hazard ratio of 0.98. So significant. Now when they showed the data, and I think this is fairly disingenuous, they show the difference in the median of 7.5 months, but we all know that's a point estimate. Those curves, it is what it is, Brian. - It is what it is, but it doesn't necessarily capture the benefit of RPFS. - We do routinely show the medians. It's not like they've done the 25th centile, the 75th centile. - You just don't like it that much. So that's the problem. - Well, I think most of, this is all public from the ODAC hearing, most of the benefit, in fact, all of the benefits in the 99 or 100% population, right? If you look at the 90 to 98, that hazard ratio is actually above one. So I think it's a very tiny fraction of patients who will benefit from this. I gave the company credit for doing a biomarker directed study. We yell about that all the time. And so AstraZeneca actually did it. But it's also, there are tolerability issues with the drug. And you see some of the numbers that are on the screen here. So it's not, you know, from a benefit-risk perspective, I think it's pretty close. I think it'll get used in those very high patients, but I don't know about broad use of this drug. - And Brian, in the ODAC itself, there was a voting, most people voted to accept it. Did that surprise you in terms of how the conversation went? - It did surprise me. I thought there'd be mostly noses and symbiases. So I can't speak for the other members. I think when people go around the room and say how they voted, people like, yeah, RPS. And they kind of hemmed in hot a little bit. I didn't personally hear any compelling arguments. So again, I think it just comes down to what is the value of RPS balanced against toxicity without OS? These are not the bracket curves from talopro3, right? These are kind of the opposite. - Indeed, for this marginal benefit, and when you're tying in some of the side effects, hyperglycemia rash, diarrhea for something to keep in mind, you have used this drug in breast cancer, but also not to forget deaths as well. That was 7.2% with KapivaSertib, Abi+ ADT arm. And when you compare that with 5.2% with Abi+ ADT, so something to keep in mind with that very marginal benefit inside effect profile. - It's really interesting in breast cancer, and I only learned the data for that ODAC. I don't see those patients. The benefit is much more and the risk is much less. - Right. - So it's clearly a different drug in different settings - Indeed. - Something like 20% of patients required insulin. That's a huge number, not permanently. - Right. - And at least short term, that's a big number. - Yep. - All right, now moving along into bladder cancer space. I know, Tom, you've been waiting to talk more about this, so let's dive right in. What we saw days before ASCO was approval of Dervaulamab with BCG based off of Potomic trial. Tom, I'll come to you, but Brian, any quick thoughts on this study and findings? - I mean, I don't know that the ASCO data necessarily changed my mind about anything. In terms of an update, I thought it was a relatively minimal update. I think my opinion, I think our opinion has been for a year of immune therapy with its attendant side effects for the gains that we're seeing is a lot. And I'll be really interested to see if this drug is used in the community. Is the urologists who see these patients, not us, we don't see them unless they're sent to us? Urologists like to give intravascular therapy. Now there are a number of these therapies. So I kind of think the intravascular therapies will still dominate this space. - Tom, your thoughts are. - Look, I think this is quite a long discussion, isn't it? Because it's a trial that was really well conducted, but it wasn't the only trial in this space. - Indeed. - There was a Sassali Mab trial with a similar design, which is also a PD1 inhibitor, two years of therapy rather than one, with exactly the same hazard ratio of the Ventory Survival of 0.68. The way you define events is really important because some of these events aren't live-threatening and many of these events, if you look at cystectomy rates and you look at metastasis-free survival and we talked about, I was a bit rude about the prostate study a few seconds ago, but they did show up an MFS advantage. And that sort of endpoint that patients have worried about, what's the chance that cancer coming back and killing me? Those are really, those are questions we get asked in clinic. And how much therapy do we need to give with the chances of life-changing toxicity to prevent a local recurrence? And it's not like these patients aren't going to have surveillance anyway. Many patients will buy into that, but you're still having to do the three months, it's not exactly, and if you're scraping out something, well, how much difference does that make? And how much does that offset the risk associated with long-term arthritis and long-term other issues? So I struggle with this a little bit. Also, there was the Alban trial, the Teslasm study that was negative in this space. Now, there are perhaps patients, and I think this is why the FDA approved it. There are perhaps patients where, they're never going to have cystectomy. And they potentially do have quite aggressive local disease. And they'll say, is there anything I can do to reduce the risk of that happening? And so maybe there is a small percentage of patients where this isn't attractive. And that's what Maria DeSantis who led the trial, that's what she said when she's presented this data at ASCO. But the benefits, what it does show us, 'cause the patient's at risk population is low, you can still control arm, bottom line from this, number one, BCG induction rate and is brilliant. In the local community, give BCG well. That's really important. And that's almost the most important message from this. Number one, and of course, number two, is it does show that immune checkpoint inhibition probably works really well earlier in disease. But because this population is not at immediate risk of getting into trouble, it doesn't translate necessarily to immediately clinically meaningful endpoints. - Can I quickly jump here? I think that what's important is taking that step back and in this selected group, what are we trying to do? We're trying to decrease the risk of this early tumor turning into muscle invasive disease. And for that muscle invasive disease is where we're talking about systemic treatment and cystectomy. So here, the idea of Potomac for one year of immunotherapy is, can we decrease the risk of event free survival? We're not talking about overall survival here. And to me, these are going to be very, very long discussions with our patients. But as a medical oncologist, when you're getting referred to a good amount of patients, we are going to play a bigger role, but this is going to be in a very small subset where you're jumping on and saying, this is the right treatment. All right, now let's shift gears to metastatic disease. We saw an ASCO update for EV302. Tom, this is your study, which resulted in doubling of overall survival with EVPembro in metastatic bladder cancer. This is now the go-to standard of care. Take it away. What are we learning here at ASCO? So it's a study which is a metastatic urethema cancer. It's 900 patients. Essentially, unfortunately, we have a doton in Pembrolyzumav until progression. And chemotherapy with maintenance of allumav in 30% of patients. The rest just got chemotherapy, Gemesis, or Gem Carbo. And we've previously showed a doubling in OS and progression-free survival, response rates of about 70% CR rates of about 30%. Has a ratio of 0.5, and this is the updated, it's 0.53, originally it was 0.47. So it's been very consistent, and that plateau at about 40% for zero, which is really unusual when you look back in time. The first studies we did, maybe five or 10% overall survival with platinum chemotherapy alone. And now we're managing to get that to 40% with this regime. And I guess two questions really from this study that we tried to answer. The first is what happened to those CR patients. And what we showed was a maturation of CR. So many CRs happening over a six month, or even longer a nine month period. CR doesn't happen on the first scan for two-thirds of patients. And those patients that are 30% that achieve a CR, they have 85% five year or three year survival. So yeah, you can get CRs happening with livermets, with bonemets, with all sorts. So it shows when I discuss this with my patients now, I can say, look, there are some patients that actually do really, really well. And that's different from a conversation five years ago, which was I'm afraid this all ends the same way, and we're going to try and keep the can down the road as long as we can to, yeah, there's a chance of a long term durable remission. So then that prompts the final question, how long do we need to give therapy for you? And this is a really important issue. We embarked on this journey in good faith. I wasn't convinced we would ever beat platinum, chemotherapy with anything we've done. We found it so difficult and failed so many times. So we wanted to give as much treatment as we could to get the best result we can. But we didn't answer the question about the optimal duration of therapy. And there is an issue around how long should we go for? The average number of cycles is probably about six months, actually, the average number in this trial, a bit longer of a Pembrolyzumab. But we looked at landmark of 12 and 24 months, and there were a group of patients going on for longer periods of time. What I can tell you is we don't know how long you should give therapy for. There are three important factors, baseline disease and response to therapy. Stable disease in the liver would be anxious about stopping therapy early, where CR, after a year, I'd be much more comfortable stopping. And then number two, tolerability. How's the patient getting home with therapy? There are some patients which clearly we have to stop. And then the third patient preference. There are some patients who just don't want to stop therapy. - And Tom, when you're stopping this therapy, are you just stopping the EV portion or Pembro or both? - So look, I think my personal opinion of this is two years of immune therapy feels right at the moment for advanced disease. I realize it's a year in perioperative and I realize there's not much science behind it. But I feel, so I'm going to two years of Pembro. I think it's also true that the vast majority of the side effects occur during the first six months of the immune check, but not exclusively, but the majority. So, but EV is more complicated in the long term. It causes neuropathy, it causes fatigue. So I am continuing with the Pembro. I'm trying to give as much EV as I can that's reasonable without side effects. And for those patients that have gone into a CR for a long period of time, I'm saying to patients after about a year, we have to have a discussion about how long you want to go for. - If I walk in tomorrow with advanced urethelia, what are you quoting me for a cure rate slash long-term remission? However you want to define it. - I'm sort of saying a third of patients are probably making it to five years. - Correct. - And I think that's a third of you. So I'm saying we're going to probably cure. I'm saying a third of chance of cure. That's where I am, Brian. - Come a long way. - Come a long way. - I've struggled with it. I've struggled with it. - I know you have, I've finally. - Come in that cure patient or long-term remission outside your imaging. Are you using CTDNA here? - The CTDNA story is in the perioperative space. It's been FDA approved within the context of the athesalism-arvin figure 11 trial. In the adjuvant setting for patients who are immune therapy naive, it can tell you when to start immune therapy. It doesn't tell you when you can stop perioperative immune therapy. In metastatic disease, you can get a level, a CTA level, an MTM level, basically the number of molecules per mill. And what that tells you like the PSA is the concentration. We showed in figure 11 that higher concentrations are associated with more advanced disease, less good outcomes. And we've shown CTDNA clearance in those trials are associated with good outcomes. We've also shown that in the metastatic setting for single-asian immune therapy. So that's been adopted now in the US quite widely for better or for worse, without that much data. And it's not unusual for patients to be tracking their CTDNA, showing dynamic changes with EV Pembro in metastatic disease. I would expect probably a 60% CTDNA clearance, maybe 50 to 60%. And I would expect CTDNA to become a parent, probably four to six months before radiological relapse. Whether that helps, I don't know. The danger we have is we don't have brilliant second-line therapies of switching away early to something we don't know. Is that a good idea? I don't know. Are there clinical trials where we're exploring this in breast cancer? The answer's yes. In blood cancer, we haven't quite got there yet. I worry a little bit, Tom, and you alluded to this. We're kind of sending this test, but we're not really sure what to do with the result. I don't think that's a great place in metastatic disease. Because I think it can create anxiety for patients and docs. You could imagine using it if you're saying, "Gee, should I stop? Should I nod?" And if your CTDNA is negative, you feel better. But I'm not sure that's a good enough reason. So I think there's a lot of work to do to implement that in clinical practice. And unfortunately, this is the story in almost every disease site. Yeah, perhaps. Yep. And I'd say, at least from community standpoint, we have done that in breast cancer space, lung cancer space. But again, when the results come back, we are sort of questioning why did we do that or what to do about it now. All right, moving along into our last study that is for RCC. We saw approval of Belzuda fan with Pembrolysmab after Nifrek to me in adjuvant setting. Prior to this, we have utilized Pembrolysmab alone, which was approved back in 2021 based off of keynote 564. And we have five years survival data on this. But now we have Belzuda fan and Pembro combination. Brian, can you touch on this study and who's going to be that patient that you're going to use this approach? So same eligibility, basically, as keynote 564, almost identical high-risk resected kidney cancer, some M1 NED, Pembromonotherapy standard of care, as you said, which in 564 should an 8% reduction in DFS, 5% increase in OS at that five-year follow-up. And then this added Belzuda fan, oral hip inhibitor approved in the refractory setting, being tested in multiple settings, too. So it was Pembro, Belzuda versus Pembro, DFS, hazard ratio, significant hazard ratio, 0.72. I think the follow up was about two years, right Tom? Something like that, two to three years. And we see a pretty similar reduction, about an 8% reduction, 78% from a landmark standpoint. There was not an overall survival advantage, although the hazard ratio was below one. And remember, keynote 564 took until the 57-month follow-up to become significant. So it's just a bit early to say, I think the problem for me with adjuvant treatment in general is overtreatment. And so now we've doubled down. And if we're overtreating half the patients with Pembromonotherapy, now we're doubly overtreating them. So it's a benefit-risk equation. Personally, I'm going to wait for more mature data and overall survival to adopt this in my practice. If you said you wanted to give it now, you sort of accept that overtreatment, then fine. And Belz is pretty well tolerated, but it's not without toxicity, including financials. I think it's interesting data. It's important how it's going to actually play out in practice. What I've heard from a lot of other experts is that they're going to wait for the OS data. We clearly need a marker like CTDNA. There was some data presented at ASCO by Tony about CTDNA data from an earlier Natera assay from 564, but it just wasn't sensitive enough. So as the assay becomes more sensitive and we can apply it in the setting, I think it'd feel a whole lot more comfortable. - So my take on it's slightly different. I think overtreatment is an issue. I actually think overtreatment with Pembrolyzum app is associated with more long-term toxicity than Belzutafan. My experience at Belzutafan is if you stop it, the side effects go away pretty quickly. And if you're going to start an adjuvant therapy, why not give the best drugs that you can in the knowledge that we don't yet have OS and we're going to wait and get there. My experience of the trial was when you stop the drug if they were side effects they went away. And so I don't see if I'm not suggesting for a second everyone needs to have adjuvant therapy. When I see people in I saw an 82 year old man and clinically other day, he had a few comorbidities, he just got through his big operation. He's not going to have any adjuvant therapy. And I've got no problem with that. He's high risk when he's CT scans and other bits and pieces. Hands, hammers will say, Tom, wait till the cancer comes back. Give him a opinion. I've totally bought into the concept that not everyone needs adjuvant. But if you're going to do it, why would you give something that's potentially suboptimal in the knowledge that the drug you're adding is not the one that's going to be associated with the long-term side effects. And you say, look, have a go see how you get on. If you like it, we go with it. If you get some anemia hypoxia, we stop it. It'll probably be gone away in a month or two's time. In fairness. And we'll go by the way. Number one, you're an authorized. We should reveal for conflict of interest. Number two, you don't really know that, right? We don't really have data to suggest, oh, the side effects go away. Oh, it's not a big deal. Oh, it doesn't potentially immune toxicity, right? We don't know. I'm going to a lot of studies. And I can say what I think, this is what I think. And I don't think I'm particularly by, I've been very negative about a lot of the studies I've been involved with tropics for, with chastitudes. Oh, OK. All right. So I'm happy to take-- I'm happy to say I wasn't on the prostate cat at the studies. I agree with that. The rest of it. I was on Potomac. I was on Potomac. I feel unbalanced on this. I genuinely think that if you're going to embark on a journey in the adjuvant setting with a drug with significant adverse events, like Pembrolysmab, adding a second drug with transient adverse events, not insignificant, but transient. And this is not metastatic disease. You're not on this drug for the rest of your life. We're looking for 10 and 20 years outcome. So take this and see how you get on. And it's not associated with high treatment related mortality. My feeling on this is actually, this is OK in that respect. And at the moment, if you take Brian's logic to its natural conclusion-- of course, this is another trial I'm conflicted on-- the adjuvant Pembrolysmab study-- that had similar data at this point, and that ended up achieving overall survival. And of course, the issue with these patients is they can't go back in time. You've got to make a decision now. And they can't go, oh, I'll wait for the OS signal and see where that comes out. You need to make a decision now. And for those individuals looking for the best possible outcomes, particularly those who choose adjuvant Pembrolysmab, I would say adding the second drug is entirely reasonable at this point. And I'm not saying it's unreasonable to use. I'm not at all saying that. I'm just giving you my own personal. I worry more about the half of patients who will never recur than I do about the patients who are going to recur, where we have life extending therapies. We're short in time here. Just to close the chapter here, I have mixed feelings. I don't think I'm jumping on for all comers that meet the inclusion criteria, even though the side effects of hypoxia andemia are getting better, that quality of life, the minute that patient starts to feel fatigue, and there's a chance we're overtreating, that's not the best. That's sad. Am I going to wait four or five years to see that overall survival and then change our practice? I don't know. So I think that for that small group with high risk, I do think that doublet might be the right option. Whereas for someone else, like you brought up elderly frail, early disease, I don't think I'm jumping on this doublet. You know, we flew through a lot of data here, six studies, prostate, bladder, RCC and all this data and approvals happen in the last roughly four weeks. Brian and Tom, thank you so much for joining us and walking us through all this. Those tuning in, let's go over a quick recap. In today's discussion, we focus on G. E. Malignan, C. Highlights from ASCO 2026, with Dr. Brian Rene and Tom Powell's, GoHos of EuroMegos podcast. Here we had a chance to touch on three studies presented at ASCO 2026, but we also touched on three recent approvals in this space that we just got around ASCO. Starting with Proteus, where periop, epilutamide and ADT in high risk localized or locally advanced prostate cancer improved PCR or MRD from 1% to 9%. And this also improved the metastasis free survival. But there's a lot more to the story than just meeting its primary endpoint. This control of fear representation of what we see in our clinical practice. For that high risk patient who prefers radiation or research, how do we extrapolate this data? Then in prostate cancer, we brought up the recent approval of capyris certab. We already have this drug approved here for breast cancer. And now in prostate cancer for PTEM loss, mutated disease, this should be on our radar. As this particular subset carries a poor prognosis. Right Rahul, with capyris certab, with a marginal benefit, let's not forget the side effects that it comes with. That is hyperglycemia, rash, diarrhea. This approval is based off of capetello 281, where capyris certab was given four days on and three days off while continuing on with the ADT and Abbey Ratterone portion. Then in bladder cancer, we touched on the recent approval of Dervalumab with BCG, in non-muscle invasive bladder cancer space based off of Potomac trial. We have to be careful selecting that particular right patient with high risk features. As with Dervalumab, it comes with its fair share of side effects and the drug is supposed to be on for one year. And to close off the chapter with bladder cancer, we covered EV302 update from ASCO 2026, where we continue to see doubling off overall survival at three and a half years that has maintained for 33.6 months with EV Pembro arm versus 15.9 months from chemotherapy. This continues to remain our current standard of care. Bro, the EV Pembro is also now approved in muscle invasive bladder cancer. So we're using this combination more and more in our clinical practice. With this drug, we need to keep rash, neuropathy, and hyperglycemia in mind. To close, we touched on recent approval of Belsutafan and Pembro wasmab in RCC based off light spark 022 study. We're at two years, disease free survival is roughly 81% with the combination versus 74%. So this is all happening in adjuvant settings. There is a clear theme here. As our patients live longer with these interventions, we need to do better with adverse events that come along with our interventions. With Belsutafan, we have to keep anemia hypoxia in mind when it comes to side effects. Thanks for tuning in. See you in our next episode. And if you've not already checked out, make sure to check out EuroMegos podcast with Dr. Brian Rene and Tom Powell's. We are the oncology brothers.