ASCO 2022: Real-World Treatment Patterns and Clinical Outcomes with First-Line Therapy in Cisplatin-Eligible and Ineligible Patients with Advanced Urothelial Carcinoma

(UroToday.com) At the 2022 American Society of Clinical Oncology Annual Meeting held in Chicago and virtually, the poster session focused on Kidney and Bladder cancers on Saturday afternoon included a presentation from Dr. Guru P. Sonpavde examining real-world treatment patterns and outcomes for patients receiving first-line therapy for advanced urothelial carcinoma (UC).


Advanced UC has been long recognized to have a poor long-term prognosis. While cisplatin-based chemotherapy remains the guideline recommended treatment approach for those who are eligible, recently, there has been clinical trial data support immune checkpoint inhibitors targeting PD-1/L1 both as maintenance therapy for those who are cisplatin-eligible and as an alternative first-line therapy for those who are ineligible. However, it is unclear the degree to which these approaches have been adopted in real world practice or their outcomes in this setting.

Thus, the authors sought to perform a retrospective observational study examining contemporary first-line treatment patterns and associated overall survival outcomes among patients with advanced UC. To do so, these use data from the nationwide Flatiron Health longitudinal electronic health record-derived database, comprising de-identified patient-level structured and unstructured data. They included adult patients diagnosed with aUC from May 2016-Oct to 2020 and stratified them on the basis of cisplatin-eligibility. Patients were followed until death or end of data availability in July 2021 to assess overall survival which was estimated using Kaplan-Meier methods and compared via multivariable Cox proportional-hazard models adjusted for clinical covariates.

The authors identified 4,300 patients diagnosed with aUC of whom 3,311 (77.0%) received first-line treatment. In this cohort, 1836 (55.5%) were deemed to be cis-ineligible while 1475 (44.5%) were deemed cis-eligible. As expected, there were notable differences between these groups with cis-ineligible patients more likely to be older (mean age, 75.0 vs 69.0 years), have lower creatinine clearance (median, 45.3 vs 80.7 mL/min), and worse ECOG-PS (2+, 29.2 vs 0%). Notably, only 44.4% received second-line therapy, though this was higher (52.0%) among the cis-eligible group than in the cis-ineligible patients (38.3%).

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Median OS among all patients who received first-line therapy was 11.0 (95% CI, 10.3 – 11.5) months. Not unexpectedly, median overall survival was shorter in cis-ineligible than cis-eligible patients (8.6 [95% CI, 8.1 – 9.2] vs 14.4 [95% CI, 13.4 – 16.4]; hazard ratio [HR], 0.8 [0.7 – 1.0]).

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Interestingly, a number of patients deemed cis-ineligible actually received cis, and many cis-eligible patients did not, highlighting that physicians consider many clinical factors beyond conventional criteria to determine cis-eligibility. Independent of cis-eligibility, receipt of cisplatin based chemotherapy (either cisplatin and gemcitabine or MVAC) was associated with longer overall survival, compared with other treatment approaches.

Thus, Dr. Sonpavde concluded that clinical outcomes remain generally poor for patients with advanced UC receiving first-line therapy, with particularly worse outcomes for those who are cisplatin ineligible. Further, many patients did not receive first-line therapy and, among those who did, the majority did not receive second-line therapy.

Presented by: Guru Sonpavde, MD, Bladder Cancer Director, Dana Farber Cancer Center, Faculty, Harvard Medical School, Boston, Massachusetts