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Treatment Approaches for Cisplatin-Ineligible Patients with Invasive Bladder Cancer

  • David J. Einstein
  • Guru SonpavdeEmail author
Genitourinary Cancers (S Gupta, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Genitourinary Cancers

Opinion statement

Cisplatin has been established as an important agent in the neoadjuvant setting prior to radical cystectomy (RC) surgery for muscle-invasive urothelial cancer (MIUC) as well as in the unresectable or metastatic urothelial carcinoma (mUC) setting. Unfortunately, many patients in practice are felt to be “cisplatin-ineligible.” Thus, it is vital that we develop treatment approaches and novel therapeutics for this population. We evaluate therapeutic alternatives to cisplatin-based treatment. For patients undergoing RC, there is no recommended alternative to neoadjuvant cisplatin-based combination therapy, and upfront RC or clinical trials are preferable. For patients receiving “bladder-sparing” radiation, concurrent radiosensitizing chemotherapies may be used, and several trials are also underway. For cisplatin-ineligible patients with mUC who are eligible for chemotherapy, carboplatin-based or split-dose cisplatin-based regimens may be employed. Pembrolizumab and atezolizumab offer options as first-line therapy for cisplatin-ineligible patients with high PD-L1 expression. The results of trials combining checkpoint inhibitors or platinum-based chemotherapy plus PD1/PD-L1 inhibitors are eagerly awaited. For platinum or chemotherapy-ineligible patients with mUC, immune checkpoint inhibitors such as inhibitors of programmed death-1/programmed death-ligand 1 (PD-1/PD-L1) are approved regardless of PD-L1 expression. However, given limited effectiveness of first-line PD-1/PD-L1 inhibitor monotherapy in tumors with low PD-L1 expression, trials in this space are critical.

Keywords

Bladder cancer Cisplatin-ineligible Renal impairment Chemotherapy Immunotherapy 

Notes

Compliance with Ethical Standards

Conflict of Interest

David J. Einstein has received research funding (paid to Beth Israel Deaconess Medical Center, Boston, MA) for clinical trials from Bristol-Myers Squibb and TrovaGene.

Guru Sonpavde has received research funding (paid to Dana-Farber Cancer Institute, Boston, MA) for clinical trials from Boehringer Ingelheim, Bayer, Onyx-Amgen, Pfizer, Merck, Sanofi, Janssen, and Celgene; has received compensation for service as a consultant from Pfizer, Genentech, Novartis, Merck, Sanofi, Agensys/Astellas, AstraZeneca, Biotheranostics, Exelixis, Bristol-Myers Squibb, Janssen, Amgen, Eisai, and the National Comprehensive Cancer Network; has received CME lecture fees from Clinical Care Options; has received speaker’s honoraria from Physicians Education Resource, OncLive, and Research to Practice; has been a member of the data safety monitoring board of a trial funded by AstraZeneca; and has received honoraria from UpToDate for authorship of an education chapter/review.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Beth Israel Deaconess Medical CenterBostonUSA
  2. 2.Lank Center for Genitourinary OncologyDana-Farber Cancer InstituteBostonUSA

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