Clinical Practice Experience with Avelumab First-Line Maintenance in Urothelial Carcinoma - Episode 3

The Evolution of Therapy Sequencing in Advanced Bladder Cancer

Experts discuss the changing field of advanced urothelial carcinoma and consider sequencing of therapy.

Daniel Petrylak, MD: It’s going to be very interesting to see how the field develops over the next several years. This is going to be a challenge for clinicians because we do have the FDA approval of nivolumab as adjuvant therapy for 1 year in those patients who’ve undergone cystectomy. T2 disease or higher for those patients who’ve had neoadjuvant chemotherapy, for T3 or higher for non-neoadjuvant patients who want to receive cystectomy. Predominantly platinum ineligible patients. But now you’re going to see checkpoint therapy moved up into the earlier stage of disease. So the question is going to be, are we going to use the same maintenance therapy when these patients become metastatic or if they become metastatic? And then that really shifts your whole treatment paradigm in terms of, can we re-induce a patient with a checkpoint after a certain period of time? What’s your experience been in other tumors with rechallenging with checkpoints? There’s not a lot of experience in bladder cancer.

Donald Barry Boyd, MD, MS: I have another patient who just progressed after gastroesophageal. Actually, in the lung cancer group, it depends on progression. So there’s 1 study that came out of the Journal of Thoracic Oncology. Patients who progressed with limited disease in nodal areas, who got targeted therapy to those nodal areas, and then went back onto checkpoints actually had a sustained response after that. So it depends on the nature of the response, whether you can control local disease through other means, and then go back onto the checkpoint. So I do think there’s still an argument that it may be the radiation [that] creates that abscopal effect that also may induce an increased response.

Daniel Petrylak, MD: I think in the melanoma studies [they] are allowing patients if they’ve had immune therapy, if they’ve progressed after 6 months, that counts as being able to be re-induced. So again, I think that’s going to be an important question that we have to answer in the future. That has a direct relevance as far as maintenance therapy is concerned.

Transcript edited for clarity.