EAU 2017: State-of-the-art Lecture: Is There Still a Role for Chemotherapy?

London, England (UroToday.com) Dr. Aristotle Bamias from Greece had the important role of delivering the State-of-the-Art Lecture on “Is There Still a Role for Chemotherapy?” for bladder urothelial carcinoma in the era of Immuno-oncology at today’s EAU 2017 annual congress. Dr. Bamias reviewed the EAU guidelines noting that patients should be offered neoadjuvant chemotherapy for T2-T4a cN0M0 bladder cancer, specifically cisplatin based regimens (Grade A evidence). On meta-analysis, there is only an absolute overall survival benefit of 5% at 5 years for neoadjuvant chemotherapy. There is only a Grade C recommendation for adjuvant cisplatin-based chemotherapy for patients with pT3/4 and/or pN+ disease if no neoadjuvant chemotherapy has been given. Importantly, as Dr. Bamias points out, 40-50% of patients are ineligible for cisplatin based chemotherapy at any time point in their disease course, typically from acute kidney injury, poor performance status, etc.

In 40 years of combination chemotherapy for bladder cancer, what we have learned is (i) that urothelial cancer is a chemosensitive disease, (ii) we must risk-stratify by ECOG status and disease sites, (iii) long-term disease-free survival is possible, (iv) selection of patients is key, and (v) there is value in multimodality approaches for “inoperable disease.” Chemotherapy continues to perform poorly after relapse from first line chemotherapy, although vinflunine is approved in this setting. Given other presentations from today’s session, this role will likely be filled by immune therapy agents.

According to Dr. Bamias there are a number of unmet needs of chemotherapy in urothelial cancer, including the need for (i) increased efficacy of perioperative systemic therapy, (ii) increased disease-free/cure rates for cisplatin-eligible patients in the advanced setting, (iii) more effective therapies for cisplatin-ineligible patients, and (iv) more effective therapies for relapsed disease. Two key trials are currently ongoing. The IMvigor130 study is aiming to recruit 1,200 patients that are platinum eligible, with good performance status and locally advanced/metastatic disease to be randomized 1:1:1 to gemcitabine/cisplatin + atezolizumab vs atezolizumab vs gemcitabine/cisplatin + placebo. The KEYNOTE-045 study is aiming to recruit 542 patients with metastatic disease who progressed after 1-2 lines of chemotherapy to be randomized to receive pembrolizumab vs paclitaxel or docetaxel or vinflunine. In summary, the role for chemotherapy moving forward will likely be in combination with immune therapy agents, although cisplatin ineligibility continues to remain a legitimate issue in this patient cohort.

Speaker(s): Aristotle Bamias, National & Kapodistrian University of Athens, Athens, Greece

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto

Twitter: @zklaassen_md

at the #EAU17 - March 24-28, 2017- London, England
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