Expanding Options for Cisplatin-Ineligible Bladder Cancer

Dr Thomas Flaig from the University of Colorado Anschutz discusses a paradigm shift in treating urothelial carcinoma patients who are traditionally considered cisplatin-ineligible due to insufficient kidney function. For years, cisplatin eligibility served as a critical bifurcation point in treatment decision-making. While cisplatin has long been valued for its high response rates, its nephrotoxicity has historically limited its use in patients with compromised renal function.

Dr Flaig highlights that the combination of enfortumab vedotin (EV) plus pembrolizumab has fundamentally changed this landscape. This highly effective regimen, which previously demonstrated impressive outcomes in advanced metastatic disease, is now safely available to patients with renal impairment—a population previously excluded from optimal treatment options. The ability to deliver this powerful combination even in the setting of compromised kidney function represents a significant clinical advance.

Extending beyond metastatic disease, Dr. Flaig notes that emerging data now support the use of EV plus pembrolizumab in the neoadjuvant and adjuvant settings for patients with muscle-invasive bladder cancer who are cisplatin-ineligible. This "sandwich approach"—administering the regimen before and after surgery—broadens curative-intent treatment options to a wider patient population.

Overall, Dr Flaig emphasizes that the traditional cisplatin eligibility paradigm is evolving. With effective, tolerable regimens like EV plus pembrolizumab now available, patients with compromised renal function are no longer relegated to suboptimal alternatives. This shift enables more patients to receive highly active, contemporary therapy across both metastatic and localized settings, reflecting a more inclusive and effective approach to bladder cancer care.