Experts discuss frontline immunotherapy for metastatic urothelial carcinoma when chemotherapy may not be an option.
Peter H. O’Donnell, MD, PhD: Maybe I’ll ask one last question about this sort of frontline decision point. We did have half the audience pick pembrolizumab [Keytruda] here. It certainly has an FDA label indication for a patient just like this. This patient could certainly be declared cisplatin ineligible with the PS [performance status] of 2. The patient had high PD-L1 [programmed death-ligand 1] expression. So maybe I’ll ask Matt here about this. And Cora, I’ll let you chime in, in a minute. So where for a patient that you’re thinking about immunotherapy, are there patient factors where it really makes you worry if you use immunotherapy here?
Matthew T. Campbell, MD, MS: Yes, and I’m back to the frontline studies. There’s about a 23% death rate at 3 to 4 months for frontline immunotherapy, and that always gives me some pause. But I’m most concerned about patients that have very big, bulky disease burden and particularly patients with liver metastasis, tended to be some of our toughest patients to treat. I think the data that I’ve seen with immunotherapy studies in urothelial cancer, those patients have really, I think, done poorly. So patients with high disease and high visceral liver metastasis can benefit from a more cytotoxic approach as compared to starting right with immunotherapy.
Peter H. O’Donnell, MD, PhD: Go ahead Cora; I can tell you really want to say something.
Cora N. Sternberg, MD: No, I think that that makes a lot of sense and I think that patients with visceral disease where you need a rapid response—immunotherapy doesn’t give you a rapid response. Maybe it gives you a long-lasting response but not a rapid response. Chemotherapy gives you a more rapid response. The way I look at it is that the immunotherapy upfront is for patients who are platinum ineligible. It doesn’t mean cisplatin ineligible, that means also carboplatin ineligible is what they’re talking about. So the patient has to be eligible. A patient I’m treating right now upfront is 94 years old and I don’t think I really want to give him any chemotherapy. So it’s chemotherapy ineligible. That’s also carboplatin ineligible. I think that is what is meant by the patients having PD-L1 positive upfront immunotherapy being platinum ineligible.
Transcript edited for clarity.