Dr Bochner on Key Points for Community Oncologists in the Management of Muscle-Invasive Bladder Cancer

Bernard H. Bochner, MD, FACS, urologic surgeon, Memorial Sloan Kettering Cancer Center, discusses considerations clinicians practicing in the community setting should be aware of when treating patients with muscle-invasive bladder cancer (MIBC).

Approximately 60% of patients with MIBC are candidates for treatment with a platinum-based regimen, including gemcitabine, cisplatin, and/or methotrexate, vinblastine sulfate, doxorubicin hydrochloride (Adriamycin), and cisplatin (MVAC), with healthier patients being pushed towards dose-dense regimens, Bochner begins. However, there is a significant subset of patients who will not be eligible for platinum-based treatment due to comorbidities, Bochner continues. In this setting, several large randomized clinical trials are underway aiming to identify the best course of treatment for these patients, Bochner says.

Studies are evaluating checkpoint inhibitor monotherapy, dual checkpoint inhibitor combinations, and combinations with antibody-drug conjugates and checkpoint inhibitors, with the ultimate goal of increasing the number of patients who can be down staged, Bochner notes.

Ongoing studies in the neoadjuvant setting include the phase 2 ABATE study (NCT04289779) of atezolizumab (Tecentriq) with cabozantinib (Cabometyx), the phase 3 KEYNOTE-866 trial (NCT03924856) of gemcitabine plus cisplatin with or without perioperative pembrolizumab (Keytruda), and the phase 3 KEYNOTE-905 study (NCT03924895) of pembrolizumab with or without enfortumab vedotin-ejfv (Padcev).

In the adjuvant setting, there are several available options, Bochner continues. Although overall survival data with these regimens are not yet mature, the risk of recurrence is decreased by approximately 30% or more with these regimens, especially in patients with PD-L1–positive disease, Bochner notes. Patients with previously treated disease who have invasive disease following surgery are at a high risk of recurrence, as are patients with extravesical disease who did not previously receive chemotherapy, Bochner says. As such, it’s imperative to relay to patients that, based on high level evidence, a year of checkpoint inhibitor therapy may significantly improve their outcomes, Bochner concludes.

Clinicians referring a patient to MSK can do so by visiting msk.org/refer, emailing referapatient@mskcc.org, or by calling 833-315-2722.