In light of individual patient needs, perspectives are shared on the roles of palliative radiation and treatment breaks in the setting of advanced bladder cancer.
Petros Grivas, MD, PhD: And if progression happens, [it’s] no good…There’s a plethora of other options— antibody-drug conjugates…and erdafitinib for selected patients.Emily, if we have a patient with a progression, let’s say in avelumab or another treatment, [and] they have a particularly painful area. Could you comment on the role of palliative radiation in that context?
Emily S. Weg, MD: So of course there’s a role for palliative radiation for symptomatic or painful metastases. I think 1 field that is understudied and less promising for bladder cancer is the role of stereotactic radiation in the setting of metastasis-directed therapy for oligo-recurrent or oligo-progressive bladder cancer. There’s minimal data, but [although] that approach is promising in other types of diseases, even within the genital urinary world, it’s a very promising strategy for some [patients with] prostate cancer. There is not a lot of rationale to support the use of metastasis-directed therapy for oligo-progressive bladder cancer. For a symptomatic lesion, it’s a totally different story. And palliative radiation is a really important tool for these patients as they develop more advanced disease.
Petros Grivas, MD, PhD: [I] totally agree. And there’s definitely a need to develop strategies and trials for oligometastatic disease. We have more data on prostate cancer and we’re developing more data there. But in urothelial cancer, we don’t have that much data and are worried that this is a systemic disease and we try to control it. I think it’s a case-by-case scenario in patients with prolonged benefits to systemic therapy. Do you do any consolidative approach? And as we get better with systemic therapies, I think this question will come more and more. Lisa, you discussed this before, but do you ever have a patient who is on avelumab maintenance and develops an infusion reaction or tells you I cannot come every 2 weeks? Do you ever switch to pembro [pembrolizumab], for example, in that setting?
Lisa Adams, PA-C: We haven’t run into that problem, but usually what I’ll educate patients on is that if they have special circumstances come up, a family visit or a special trip they have planned and they want to extend the interval, I mean, just because we also see that holding therapy for toxicities, we don’t tend to lose control of disease very rapidly. So we’re pretty comfortable just flexing the schedule of infusion around their life plans and what their needs are. Again, just [having] that discussion that we may not have data to support longer intervals, but if a patient says, “Well, I might just stop if I can’t accommodate a certain schedule,” then we’ll work with the patient on that. As you pointed out earlier when we have these exceptional responders to immunotherapy and if they’ve been in NED [no evidence of disease] for 1 or 2 years having that discussion, is there still a benefit continuing? I think that’s an important discussion and some interesting data in some other tumor types of melanoma, people who’ve responded very well to pembrolizumab and been in NED for years, there are some small studies looking at possibly just stopping. So I think that’s an area a lot of physicians are considering.
Petros Grivas, MD, PhD: Absolutely. And as we accumulate more knowledge and more data, it’s interesting to learn together and collectively with real-world data, and that gather very interesting. As we try to collect our database, we have fellows and residents interested in collecting real-world data from their practices. Lisa, in our practice here, we try to see how the real practice patterns work. But I agree with you that we try to stick as much as possible with level 1 evidence of avelumab every 2 weeks until the progression of toxicity. And we try to adjust if we need as possible for patient preference. But that’s our usual pattern, to try to stick with level 1 evidence as much as possible.
Just to move the discussion forward, I j want to point out there are a plethora of trials in the frontline setting and other lines of therapy looking at different strategies. For example, building upon avelumab maintenance, we know that single-arm avelumab prolonged survival, overall survival, and progressively survival. Can we build upon that and use combination strategies? So there are trials, for example, the MAIN-CAV [NCT05092958 ; JAVELIN Bladder Medley [NCT02603432]; the TROPHY-U-01[ NCT03547973] cohort 4, 5, and 6; PRESERVE-3 [NCT04887831]; and ATLANTIS [EudraCT number 2015–003249-25], [among] other trials. But we try to look at different combinations and see if avelumab alone is enough, or if we can build upon and improve outcomes with combinations. And that’s an ongoing effort in trial design. And we always encourage patients or offer them the opportunity to participate in clinical trials because that’s how we make progress. And that’s how we can build upon the standard of care, such as the JAVELIN Bladder 100 trial [NCT02603432]. So we always think about that as a preferred approach.
Transcript edited for clarity.