KOL Insight on Bladder Cancer
Treatment Algorithm for Non-Muscle Invasive Bladder Cancer (NMIBC)
Depending on the features of the NMIBC, patients are categorized into low, intermediate, and high risk:
- Low-Risk Patients: Receive a single shot of mitomycin during the rigid cystoscopy and proceed to a surveillance program.
- Intermediate-Risk Patients: Undergo a six-week course of intravesical mitomycin.
- High-Risk Patients: Treated primarily with BCG instillations for induction and maintenance, with some being offered a cystectomy as initial treatment.
Treatment of High-Risk Patients
- Cystectomy: Approximately 28.6% of high-risk patients are treated with a cystectomy.
- BCG Therapy: The remaining 71.4% receive intravesical BCG.
Platinum-Ineligible Patients
- Gemcitabine and Carboplatin: Used as first-line treatment if platinum is not an option.
- Atezolizumab: Available in the UK for PD-L1-positive patients.
- Pembrolizumab: Still listed in the product label globally for PD-L1-positive patients.
Immunotherapy and Maintenance Therapy
- Front-Line Therapy: Gemcitabine and carboplatin are preferred if platinum is suitable.
- Maintenance Avelumab: Most patients receive avelumab as maintenance therapy after initial treatment.
- Second-Line Therapy: Used after failure of platinum-based chemotherapy.
Unmet Needs in Bladder Cancer
- Non-Muscle Invasive Disease: Highly expensive to manage due to high frequency and costs.
- BCG-Unresponsive Disease: Significant unmet need for patients who do not respond to BCG.
- Metastatic Disease: Minimal curative success, leading to significant unmet needs.
Current Challenges
- BCG Shortage: Leads to risk-stratified shortened courses of maintenance BCG.
- Neoadjuvant Chemotherapy: Approximately 75% of eligible patients receive neoadjuvant chemotherapy, with 90% being suitable candidates.
Future Directions
- EV-302 Trial: Key in determining the future of combining immunotherapy with platinum-based chemotherapy.
- PD-L1-Positive Patients: Potential for atezolizumab and pembrolizumab in specific patient populations.
This summary captures the key points and data related to the treatment algorithms, patient categorization, and ongoing challenges in managing bladder cancer.
