A Podcast on Practical Considerations in Patients with Advanced Urothelial Cancer Receiving First-Line Cisplatin- or Carboplatin-Based Chemotherapy Followed by Avelumab Maintenance in a Changing Therapeutic Landscape - Beyond the Abstract
Beyond pre-existing comorbidities that we highlighted including neuropathy and hyperglycemia or clinicopathologic characteristics that may render more favorable outcomes to platinum-based chemotherapy such as lymph node-only disease, it should be noted that a few additional factors may impact the choice of first-line systemic therapy regimens in metastatic UC. Firstly, despite the increasing implementation of EV plus pembrolizumab or cisplatin, gemcitabine, and nivolumab that is expected based on recent FDA approvals, EV plus pembrolizumab is still not widely available throughout the rest of the world. For example, although drug applications are under review for EV plus pembrolizumab by the European Medicines Agency (EMA), China’s National Medical Products Administration (NMPA), and Japan’s Ministry of Health, Labour, and Welfare (MHLW), this first-line combination has not been formally approved outside of the U.S. Notably, only the first-line combination of cisplatin, gemcitabine, and nivolumab has been approved in the European Union as of May 29, 2024. Therefore, the availability of the newer EV-302 and CheckMate 901 regimens may be limited in various countries. Financial considerations inclusive of inpatient reimbursement policies and overall chemoimmunotherapy stewardship may also render the JAVELIN Bladder 100 treatment approach more feasible.
For example, in patients with hepatic impairment where safety recommendations for EV plus pembrolizumab are uncertain, the feasibility of inpatient administration of platinum-based chemotherapy when inpatient chemotherapy is preferred becomes more attractive given our familiarity with dosing under such conditions. Inpatient administration of immunotherapy-based combinations can also become an issue of cost-effectiveness and inpatient billing, and thus initiation of platinum-based chemotherapy followed by administration of maintenance avelumab in the outpatient setting upon stabilization becomes a realistic consideration in such unique cases.
Written by: Jun Gong, MD, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai, Los Angeles, CA
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