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First-Line Treatments in Metastatic Urothelial Cancer: Real-World Decision-Making

By: Julia Fiederlein
Posted: Friday, May 7, 2021

Petros Grivas, MD, PhD, of the Fred Hutchinson Cancer Research Center, Seattle, and colleagues conducted a qualitative study to describe the approaches to first-line treatment of patients with inoperable locally advanced and metastatic urothelial cancer. The results presented during the NCCN 2021 Virtual Annual Conference (Abstract BPI21-004) and published in JNCCN–Journal of the National Comprehensive Cancer Network suggested that practitioners seemed to adhere to the NCCN Clinical Practice Guidelines in Oncology and considered patient preferences and goals when making treatment recommendations.

“Consistent with [the] NCCN Guidelines, practitioners reported use of cisplatin plus gemcitabine, carboplatin plus gemcitabine, and immune checkpoint inhibitors as first-line regimens in patients with metastatic urothelial cancer, dependent on clinical factors,” the investigators noted. “As the first-line metastatic urothelial cancer treatment pattern evolves with the adoption of avelumab first-line maintenance as the new standard of care and clinical trials test new approaches, future studies should evaluate changes in real-world practice, including use of PD-L1 testing.”

To explore decision-making processes, the investigators interviewed 36 oncologists and oncology nurses in the United States. In the first-line setting, providers seemed to prefer platinum-based chemotherapy regimens; specifically, they reported the use of gemcitabine in combination with cisplatin or carboplatin. Clinical criteria, such as neuropathy, ototoxicity, poor kidney function, and performance status, were typically used to assess patients’ eligibility for platinum-based regimens.

According to the providers, first-line cisplatin-based therapies have a greater risk of tolerability issues than non–cisplatin-based regimens. Oncologists recommended a total of four to six cycles of first-line chemotherapy, with an assessment of response or disease progression after two to four cycles. Providers across all practice settings seemed to describe a shift to earlier and widespread use of PD-L1 testing to inform initial and future treatment decisions. For patients who may not be able to tolerate chemotherapy, oncologists recommended first-line monotherapy with an immune checkpoint inhibitor.

Disclosure: Dr. Grivas has received institutional grant/research support from Pfizer, Clovis Oncology, Bavarian Nordic, Immunomedics, Bristol Myers Squibb, Debiopharm Group, Merck, QED Therapeutics, Kure It Cancer Research, and GlaxoSmithKline; and has served as a consultant or advisor to Merck, AstraZeneca, EMD Serono, Seattle Genetics, Pfizer, Janssen, Mirati Therapeutics, Genentech/Roche, Dyania Health, and Immunomedics.



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