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Uptodate Reference Title
Treatment of metastatic urothelial carcinoma
Treatment of metastatic urothelial carcinoma
Patients who are not candidates for surgery or radiation therapy may be eligible for systemic therapy. Goals of treatment are palliative, and supportive care should be offered. Enrollment in a formal clinical trial is encouraged whenever possible. Listed treatments are preferred options, although alternative agents that are not listed may also be effective. For patients who are ineligible for cisplatin-based chemotherapy as initial treatment, we recognize there are alternatives to the approach described above.
ECOG: Eastern Cooperative Oncology Group; NYHA: New York Heart Association; PD-L1: programmed death ligand 1; MVAC: methotrexate, vinblastine, doxorubicin, and cisplatin; FGFR: fibroblast growth factor receptor.
* Creatinine clearance <60 mL/min is not a contraindication to cisplatin chemotherapy if renal function is due to tumor obstruction and can be reversed.
¶ Patients may have appropriate performance status but otherwise be ineligible for cisplatin-based combination chemotherapy due to renal dysfunction, neuropathy, severe hearing loss, or heart failure. These patients may be more appropriate candidates for carboplatin-based combination chemotherapy.
Δ Patients not eligible for immunotherapy may be offered single-agent chemotherapy as an alternative.ΔΔ ◊ Upon progression on immunotherapy, best supportive care or single-agent chemotherapy (if ECOG performance status allows) may be offered.
§ Atezolizumab is an option for patients ineligible for cisplatin-based chemotherapy whose tumors also express PD-L1.
¥ Patients not eligible for targeted therapy may be candidates for single-agent chemotherapy as an alternative.ΔΔ
‡ Patients eligible for enfortumab vedotin include those previously treated with both platinum-based chemotherapy and immunotherapy and those who are ineligible for cisplatin-based chemotherapy and previously received one or more prior lines of therapy, such as immunotherapy.
† Although this approach was only evaluated in those who received gemcitabine plus platinum-based chemotherapy, we also offer maintenance avelumab to patients without disease progression on other platinum-based chemotherapy regimens. Patients not eligible for maintenance immunotherapy may be observed with best supportive care.
** Although erdafitinib is approved for patients with FGFR mutations who have progressed on systemic platinum-based chemotherapy, our approach is to offer erdafitinib after progression has occurred on both platinum-containing chemotherapy and on immunotherapy.
¶¶ Sacituzumab govitecan is a reasonable alternative option with a different toxicity profile from other targeted agents. Refer to UpToDate content on treatment of metastatic urothelial carcinoma.
ΔΔ Examples of single-agent chemotherapy options (if not previously received) include gemcitabine, carboplatin, vinflunine (where available), taxanes, and ifosfamide, but this is not an exhaustive list. Refer to UpToDate content on treatment of metastatic urothelial carcinoma.
