The headline finding: overall survival reached 22.4 months, rising to 29 months for patients who could complete the intended sequence of platinum chemotherapy followed by avelumab. These results mirror those from JAVELIN Bladder 100, but only for patients well enough to receive maintenance therapy.
What the abstract cannot fully capture, and what matters most for daily practice, is the sharp drop-off between treatment lines. Only 64% of patients reached second-line therapy, and just one in four accessed a third line. Rapid clinical deterioration remains a common barrier. This real-world attrition highlights a key challenge: sequential strategies work only for patients who survive long enough to benefit from them.
A second major insight concerns patients with ECOG performance status 2–3, who represented 20% of our cohort but are virtually absent from phase III trials. Despite receiving active therapy, often cisplatin-based, their median survival was only 7.2 months, underscoring the urgent need for better-tolerated, more effective upfront options for this underserved population.
These findings provide a valuable benchmark as first-line treatment paradigms shift toward enfortumab vedotin plus pembrolizumab. Notably, in the EV-302 control arm, only 20–30% of patients received avelumab, and none had routine access to EV, far from today’s real-world context. Our study helps contextualize the magnitude of benefit seen with new combinations by anchoring it to what was realistically achievable in the pre-EV era.
The message is clear: early access to the most effective therapies matters. In mUC, many patients will never reach later lines. As new combinations move forward, understanding real-world feasibility, not just clinical trial efficacy, will be essential for optimizing care.
Written by: Fabien Moinard-Butot & Philippe Barthélémy
- Department of Medical Oncology, University Hospital of Strasbourg, Strasbourg, France.