Dr Gopal on a Case Study of a Patient With Bladder Cancer

Nikhil Gopal, MD, assistant professor, urology, College of Medicine, Memphis Department of Urology, The University of Tennessee Health Science Center, discusses details from a case study of a patient with bladder cancer.

At an OncLive^® State of the Science Summit™ on urothelial cancer, Gopal and colleagues discussed a case study of a patient with bladder cancer that evolved over time. This patient presented with recurrent, high-grade, T1 disease with carcinoma in situ (CIS) despite undergoing several prior rounds of intravesical therapy, Gopal says. This was a challenging case to treat because the patient did not respond to therapy, spurring concerns that they had undiagnosed muscle-invasive bladder cancer (MIBC), Gopal notes. Furthermore, T1 disease with CIS has high progression rates, Gopal explains.

Typically, patients with this disease presentation undergo early cystectomy, which may be curative and help them avoid the morbidity of untreated MIBC progression, according to Gopal. However, the bladder cancer treatment paradigm is expanding to include therapeutic alternatives for patients who have progressed on several rounds of intravesical therapy and are not eligible for or refuse cystectomy, Gopal emphasizes. In this case, the patient refused early cystectomy, progressed to MIBC, underwent repeat transurethral resection of their bladder tumor, and was eventually diagnosed with node-positive, locally advanced urothelial cancer, Gopal says.

Regarding the role of adjuvant therapy for patients such as this one, Gopal highlights that the phase 3 CheckMate-274 trial (NCT02632409) demonstrated a disease-free survival (DFS) benefit with nivolumab (Opdivo) vs placebo in patients with MIBC who had unfavorable prognostic features. Conversely, the phase 3 AMBASSADOR trial (NCT03244384) evaluated pembrolizumab (Keytruda) vs observation following surgery in patients with localized MIBC. However, this trial did not complete enrollment because of the successful findings from CheckMate-247. AMBASSADOR showed a DFS benefit with pembrolizumab but failed to demonstrate an overall survival benefit. Given these collective trial findings, Gopal and colleagues determined that the optimal treatment for the patient in this case study was adjuvant nivolumab instead of adjuvant pembrolizumab, Gopal concludes.