Dr. Tagawa on the current state of first-line immunotherapy in urothelial carcinoma

In this video, Scott Tagawa, MD, Weill Cornell Medicine, discusses the current state of immunotherapy use in the first-line setting for patients with advanced urothelial carcinoma. Tagawa co-chaired a session at the Bladder Cancer Advocacy Network (BCAN) 2023 Think Tank titled, “Defining treatment lines in metastatic urothelial cancer: Choosing the right targets and combinations.”

Transcript

At this time, there’s really only one truly “prime-time” [level-1-evidence–supported] immunotherapy in the first-line setting and that is in a patient who has had first-line platinum-based chemotherapy and has had disease control, meaning a partial response or stable disease—we give those patients immunotherapy in the form of first-line avelumab maintenance. The major part of patient selection [for upfront avelumab maintenance] is that they have not had primary progression on platinum-based chemotherapy. And that would be kind of first-line switch maintenance therapy. The other part of patient selection would be is the patient a candidate for anti–PD-L1 immunotherapy; and that is generally a question of [whether or not they have very active autoimmune disease].

And then we’re about 3 months since the accelerated approval of enfortumab vedotin plus pembrolizumab in patients who are cisplatin unfit. In the recent ASCO recommendations about what to do in the setting of the cisplatin and carboplatin shortage, the nice thing is that enfortumab vedotin plus pembrolizumab was approved in this setting at the same time as the emergence of the severe carboplatin shortage. So, I think no one has a problem [using this regimen] provided that the patient is a candidate and doesn’t have, for instance, terrible neuropathy. The harder part is with cisplatin because we know that there’s a subset of patients—and it’s mostly those with soft tissue metastasis—that gets cisplatin-based combinations and are cured, even without maintenance immunotherapy. So that's a more difficult situation. But there’s a gray area about how much are we looking for cisplatin ineligibility? So, in the setting of cisplatin shortages, at least in this country, we may be offering enfortumab vedotin plus pembrolizumab while we’re still waiting for the head-to-head data of enfortumab vedotin/pembrolizumab vs platinum/gemcitabine from the phase 3 EV-302 study (NCT04223856). So we’ll see what happens, but it’s an exciting world in which we have all of these complications about what to do because it means we have a lot more choices for our patients.

Transcript has been edited for clarity.