Advancements in Bladder Cancer Treatment Require Multidisciplinary Team Care

Urologic oncologists are getting more comfortable with using immuno-oncologic agents, but novel combination therapies being studied will require a multidisciplinary team consisting of the urologic oncologist, a medical oncologist, a radiation oncologist, and a pathologist, explained Neal D. Shore, MD, FACS, medical director of the Carolina Urologic Research Center.

This transcript has been lightly edited for clarity.

Transcript

As bladder cancer treatment evolves to triplet therapies that improve outcomes, but also increase toxicities, how is it becoming more important to utilize a multidisciplinary team to coordinate treatment and monitor patients? 

I think in the non–muscle-invasive bladder cancer [NMIBC] space, right now we have the approval of pembrolizumab. As an urologic oncologist, I'd been very comfortable in administering PD blockers or checkpoint inhibitors, immuno-oncologic agents, since they were first approved in 2016. More and more urologic oncologists are getting comfortable with that. And I think they really do need to be attaining that level of understanding, education, and comfort, particularly in NMIBC, but if they're not, then working with their medical oncologist is a great solution.

What we've seen without getting too into the weeds of it, we've always known that platinum-based neoadjuvant application is extremely important for patients, who are about to undergo radical cystectomy, as long as they are can tolerate platinum-based therapy. They don't have contraindications.

But most recently in 2023, we had really wonderful studies—the CheckMate-901 and the EV-302. CheckMate-901 basically demonstrated that for first-line metastatic peripheral cancer patients combining gemcitabine and cisplatin and nivolumab was a remarkably successful study. In EV-302 combining pembrolizumab, a checkpoint inhibitor, much like nivolumab, with an antibody drug conjugate in the form of enfortumab vedotin, was also very, very successful. Both of these trials improved RPFS [radiographic progression-free survival] against their control arms and also extended overall survival.

Now, these are systemic therapy drugs, and most urologists are going to definitely want to have a very good discussion with their tumor boards or their multidisciplinary teams, particularly their medical oncologists for treating these patients with metastatic urothelial cancer.

We also have a lot of ongoing promising trial literature that's going to read outsometime in the near future on trimodal bladder sparing. That incorporates the multidisciplinary team of the urologist, who has to do a complete resection of the bladder lesion, but then there will be potentially chemoradiation as well as chemoimmunotherapy and even potentially getting back to the use of the TAR-200 and other modalities. You will want to be combining in your advanced bladder cancer center, your advanced bladder cancer clinic, urologic oncology, medical oncology, radiation oncology, and of course the pathologist and ongoing investigations of genetic sequencing of tumor tissue will be very important, as well.

So, we're having great advances, but it does require a multidisciplinary team, and I think that's sort of the North Star there, is to make sure that patients get optimal care.