Deciding Who Is Appropriate for Bladder Cancer Maintenance Therapy

Chandler H. Park, MD, a medical oncologist at Norton Cancer Institute and advisory dean/professor at University of Louisville in Kentucky, discusses real-world data for maintenance avelumab in bladder cancer and factors that sway his treatment selection.

After long-term follow-up, a subgroup analysis of JAVELIN Bladder 100 trial (NCT02603432) showed a cohort of patients over 80 years of age treated with carboplatin/gemcitabine followed by maintenance avelumab (Bavencio) had a median overall survival (OS) of 24.9 months. Park explains that this treatment sequence is relevant for older patients who may not tolerate cisplatin-based regimens.

Park says patient-specific factors that influence his treatment selection include the presence of liver disease, thrombocytopenia, diabetes, or pre-existing peripheral neuropathy. JAVELIN Bladder 100 chemotherapy followed by maintenance avelumab may not be right for every patient but showed prolonged OS vs chemotherapy alone.

Treatment must be individualized, according to Park, but options such as cisplatin- or carboplatin-based induction chemotherapy followed by maintenance avelumab or dose-dense methotrexate, vinblastine, doxorubicin and cisplatin (MVAC) may be a proper choice when rapid disease control is a priority.

TRANSCRIPTION
0:10 | There are some [long-term] data that Shilpa Gupta, MD, presented earlier this year. Patients greater than 80 [who were] given carboplatin/gemcitabine and maintenance avelumab, and the average OS there was close to 25 months. And so these patients, when they're older…might not be cisplatin eligible.

0:30 | Now, what about the other patients? What if our patient has liver disease, and this could be [aspartate aminotransferase and alanine aminotransferase], maybe they have underlying cirrhosis, and let's say maybe their platelet count is in the 75,000/μL to 80,000/μL range? Because one of the things about the [enfortumab vedotin (Padcev)] studies is you have to hold the medication if the platelet count is less than 75,000/μL. So those are the things I look at. Does our patient have any kind of underlying liver disease? Does our patient have diabetes mellitus? Does our patient have peripheral neuropathy? Are our patients older? Also, around the world, globally, a lot of the treatments we have to think about with a financial scope of things. This treatment tends to be a little bit...more cost effective, and so it's very effective.

1:24 | In terms of OS, if you look at the treatment, since the patient was started on chemotherapy—let's say I have a brand-new patient with stage IV bladder cancer, and we start the treatment based upon the chemotherapy day, and we followed them 4 to 6 cycles and then immunotherapy. If you start from the chemotherapy day, the average OS is actually 29.5 months with JAVELIN Bladder 100. To answer your question, every patient is different. It's not one-size-fit-all, but there's definitely room for cisplatin/gemcitabine maintenance avelumab or carboplatin/gemcitabine maintenance avelumab, and also dose-dense MVAC. Some of these patients, you want to kind of get to cancer under control really fast with maintenance avelumab.