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ASCO GU 2021

ASCO GU 2021: Approaches to Immune Checkpoint Inhibitor Maintenance Therapy in Metastatic Urothelial Cancer: A Qualitative Analysis of Oncology Providers in the United States

(UroToday.com) There were approximately 81,400 new cases of bladder cancer diagnosed in 2020 and nearly 90% of these cases are urothelial carcinoma. Unresectable, locally advanced, or metastatic urothelial carcinoma is present in nearly 20% of all invasive urothelial carcinoma cases worldwide. Immune checkpoint inhibitors have demonstrated long-term responses with tolerable safety profiles in patients with metastatic urothelial carcinoma, including avelumab as first-line maintenance therapy for patients with advanced/metastatic urothelial carcinoma that have not progressed with platinum-containing chemotherapy. This treatment approach was recently approved in the US based on improved overall survival seen in the JAVELIN Bladder 100 trial.1 However, provider perspectives regarding first-line maintenance therapy in metastatic urothelial carcinoma have not been reported. At the GU ASCO 2021 annual meeting, Dr. Petros Grivas and colleagues presented results of their study of a quality analysis of oncology providers in the US with regards to their approaches to immune checkpoint inhibitor maintenance therapy for metastatic urothelial carcinoma.


This was a qualitative interview study with US oncologists and oncology nurses treating patients with metastatic urothelial carcinoma in academic and community practices. Telephone interviews were conducted in August 2020 using a semi-structured discussion guide to explore decision-making processes about treatment for patients with metastatic urothelial carcinoma and perspectives about immune checkpoint inhibitor maintenance therapy in the first-line setting. Perspectives about immune checkpoint inhibitor maintenance therapy in the first-line setting was defined as either (i) immune checkpoint inhibitor for patients who achieve disease control with platinum-containing chemotherapy (Regimen A) or (i) immune checkpoint inhibitor plus chemotherapy followed by immune checkpoint inhibitor (Regimen B):

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Thematic analysis identified key determinants and clinical considerations associated with immune checkpoint inhibitor maintenance therapy in metastatic urothelial carcinoma.

There were 18 US oncologists (mean age 51.3 years [SD 9]; 11% female; 55% with >15 years in practice; 39% academic) and 18 US oncology nurses (mean age 43.8 years [SD 11.1]; 94% female; 34% with >15 years in practice; 50% academic) that participated in the study. Cisplatin- and carboplatin-based chemotherapy regimens were the most commonly administered first-line treatments, with immune checkpoint inhibitor monotherapy reserved only for frail (i.e., comorbid and/or elderly) patients. All oncologists recommended 4-6 cycles of first-line chemotherapy. Providers reported different perspectives about the maintenance approaches:
  • Those who expressed a preference for Regimen A (oncologists, 66.6%; nurses, 71.4%) cited potentially less toxicity as a key factor driving their choice.
  • Providers who preferred Regimen B cited the perceived potential for deeper and more durable responses based on previous experience with this maintenance approach in other tumors as a driver of their choice.
For Regimen A, providers universally did not recommend a treatment break between chemotherapy and immune checkpoint inhibitor maintenance because of concerns about disease progression. The frequency of administration was not cited as a driver of treatment decisions for either maintenance approach; instead, providers prioritized survival and tolerability. Responses were generally consistent between oncologists and nurses.

Dr. Grivas also provided several potential limitations for this study:
  • Although the sample included participants from a variety of geographic regions and practice settings, the results may not extrapolate to all oncologists and oncology nurses treating patients with metastatic urothelial carcinoma
  • The findings represent the experiences and perspectives of a small convenience sample that may be more vocal than the general medical oncologist and oncology nurse population
  • Due to the study nature, unmeasured confounders cannot be excluded and findings are hypothesis-generating
  • The interviews were conducted in August 2020, shortly after the FDA approval of avelumab as a first-line maintenance treatment. Participants in this study, therefore, had limited experience with the treatment in clinical practice, meriting future research in a larger sample of providers
Dr. Grivas concluded his presentation with the following take-home messages:

  • The oncologists and oncology nurses interviewed generally reported practices that aligned with current clinical guidelines, including National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO), for first-line treatment of metastatic urothelial carcinoma
  • At the time of the study, few providers had experience with immune checkpoint inhibitors as first-line maintenance therapy in patients following achievement of disease control with platinum-containing chemotherapy (Regimen A). However, most preferred this regimen to a regimen of immune checkpoint inhibitor plus chemotherapy followed by continued immune checkpoint inhibitor (Regimen B), which is not approved
  • These findings highlight the need to increase provider awareness of approved first-line immune checkpoint inhibitor maintenance treatment for patients who achieve disease control with first-line platinum-containing chemotherapy as a standard of care in metastatic urothelial carcinoma 
Presented by: Petros Grivas, MD, Ph.D., Associate Professor, Clinical Director of Genitourinary Cancers Program, University of Washington, Associate Member, Clinical Research Division, Fred Hutchinson Cancer Research Center.

Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia Twitter: @zklaassen_mdduring the 2021 ASCO Genitourinary Cancers Symposium (ASCO GU), February 11th to 13th, 2021

References:
  1. Powles T, Park SH, Voog E, et al. Avelumab Maintenance Therapy for Advanced or Metastatic Urothelial Carcinoma. N Engl J Med 2020 Sept 24;383(13):1218-1230.