Abstract
Simple SummaryThis report presents clinically relevant advances in the management of metastatic bladder cancer, which have been the focus of discussion of expert members of the Spanish Oncology Genitourinary (SOGUG) Multidisciplinary Working Group in the framework of the Genitourinary Alliance project (12GU) designed as a space for the integration of novel information in the care of bladder cancer patients. The present study is focused on different aspects regarding integration of immunotherapy especially in the patient unfit for platinum-based chemotherapy, PD-L1 assays and samples to be evaluated, role of imaging techniques in preoperative staging or re-staging, definition and treatment approach of oligometastatic disease, and rescue strategies in responders. Involvement of a dedicated multidisciplinary team in the care of patients with mBC is crucial to improve outcome.Based on the discussion of current state of research of relevant topics of metastatic bladder cancer (mBC) among a group of experts of a Spanish Oncology Genitourinary (SOGUG) Working Group, a set of recommendations were proposed to overcome the challenges posed by the management of mBC in clinical practice. First-line options in unfit patients for cisplatin are chemotherapy with carboplatin and immunotherapy in PD-L1 positive patients. FDG-PET/CT may be a useful imaging technique in the initial staging or re-staging. In patients with oligometastatic disease, it is important to consider not only the number of metastatic lesions, but also the tumor biology and the clinical course. The combination of stereotactic body radiotherapy and immunotherapy with anti-PD-L1 monoclonal antibodies is under investigation and could improve the results of systemic treatment in patient with oligometastatic disease. Rescue treatment with curative intent could be considered in patients with oligometastatic disease after complete response on FDG-PET/CT. Metastatic disease should be evaluated using the same imaging modality over the course of the disease from diagnosis until rescue treatment. For improving the outcome of patients with mBC, the involvement of a dedicated multidisciplinary team, including urologists, pathologists, oncologists, radiologists and other specialists is of outmost importance in the daily care of these patients.
Highlights
Important advances in the understanding of the molecular mechanisms and tumor progression of urothelial carcinoma have been achieved over the past decade
In the IMvigor210 clinical trial of atezolizumab, at a median follow-up of 17.2 months, the objective response rate was 23% and the median overall survival was 15.9 months [13], whereas in the KEYNOTE-052 trial of pembrolizumab up to a median follow-up of 5 years, the objective response rate was 28.9% [14]. In both studies durable responses were obtained. Despite these encouraging results, response rates, progression-free survival and overall survival associated with immune checkpoint inhibitors (ICI) have not been proven to be superior to carboplatin-based chemotherapy, and carboplatin-based chemotherapy remains a viable first-line treatment option in cisplatin-ineligible PD-L1positive patients with metastatic bladder cancer (mBC) until mature data from randomized phase III of ICIs will become available [15]
Assessment of PD-L1 levels in tumor tissue is currently recommended for a better selection of candidates for first-line treatment with the anti-PD-L1 agents atezolizumab or pembrolizumab in patients with locally advanced urothelial cancer, mBC or no candidates/refractory to cisplatin-based chemotherapy
Summary
Important advances in the understanding of the molecular mechanisms and tumor progression of urothelial carcinoma have been achieved over the past decade. Controversial and debatable topics of the current knowledge and approach in the care of patients with mBC were discussed by all expert members of the SOGUG and the topics to be covered by the present review were considered These include patients unfit for cisplatinbased chemotherapy and integration of immunotherapy, significance and role of PD-L1 assessment, treatment of oligometastatic disease, rescue therapy in respondent patients, and imaging techniques in the evaluation of response. In both studies durable responses were obtained Despite these encouraging results, response rates, progression-free survival and overall survival associated with ICIs have not been proven to be superior to carboplatin-based chemotherapy, and carboplatin-based chemotherapy remains a viable first-line treatment option in cisplatin-ineligible PD-L1positive patients with mBC until mature data from randomized phase III of ICIs will become available [15].
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
