Dr. Singh on Patient Selection for Immunotherapy in Bladder Cancer

Parminder Singh, MD, hematologist/oncologist, Mayo Clinic, discusses treatment selection for patients with bladder cancer.

At this point, patient selection is based on the approval or labeling indications of the drug, where the patient lies in the spectrum of disease, and whether or not they have any alternative options.

Pembrolizumab (Keytruda) and atezolizumab (Tecentriq) are both approved in first-line and second-line treatment. Durvalumab (Imfinzi), nivolumab (Opdivo), and avelumab (Bavencio) are approved for patients who have progressed on platinum-based chemotherapy.

Although physicians now have immunotherapy agents, chemotherapy responses remain to be higher. There is a chance of achieving remission with cisplatin-based chemotherapy, and physicians don't want to take away a cisplatin-ineligible patient's option with newly diagnosed metastatic disease. At the same time, once a patient progresses on cisplatin, the second-line options are limited, and responses are minimal with chemotherapy.

That's one setting in which physicians routinely use immunotherapy. Additionally, bladder cancer occurs in older patients who may not be good candidates for platinum-based chemotherapy; in those situations, immune therapy is a reasonable first-line option.