“That’s where all these immunotherapy agents are being used—in patients who cannot tolerate cisplatin or in those who progress through standard chemotherapy. Overall, prospects are not great for this subset of patients. So, anything we can do to improve response rates and survival is going to be a significant advantage,” Dr. Konety said.
Atezolizumab is among several immunotherapy agents approved for advanced bladder cancer and being studied in various bladder cancer patient types.
“Researchers are working in this space—in advanced disease, in patients who have not had any other treatment. There are trials for patients who cannot tolerate standard chemotherapy and for patients who have failed prior chemotherapy,” Dr. Konety said. “Now, there also are trials starting in patients who have not had surgery. These are not patients with disease that has spread; these are patients with localized disease and the standard of care is neoadjuvant chemotherapy. The studies are exploring the combination of immunotherapy plus chemotherapy in the neoadjuvant setting.”
Urologists will be involved in the use of PD-1 and PD-LI immunotherapy medications in the context of neoadjuvant chemotherapy, before surgery, as well as for non-muscle invasive bladder cancer, particularly because bacillus Calmette-Guerin is in short supply, according to Dr. Konety.
Positive phase III data might signal a paradigm shift for management of non-muscle invasive bladder cancer, he said.
These immunotherapy drugs tend to be generally well tolerated but are associated with increased inflammation resulting in self-limiting hepatitis, pneumonitis, etc., according to Dr. Konety.
“It’s important for urologists to get comfortable with understanding these drugs because we will be seeing these patients. Especially if patients are getting these drugs before cystectomy in the non-muscle invasive setting, we’re the ones who are going to be doing the cystoscopy and following these patients and monitoring the disease,” he said. “We need to understand how to recognize side effects and understand dosing schedules and things like that.”
Dr. Konety pointed out that while these medications are known to attack PD-1 or PD-L1 receptors, very few tumors express these receptors. It’s not yet clear why but many of these drugs show some response even in patients who don’t have the receptors, he said.
Dr. Konety is a clinical trial investigator for Merck and Bristol-Myers Squibb.