MIBC Treatment Timeline and Skin Toxicity: What Urologists Should Know

In this segment, Joshua J. Meeks, MD, PhD, the Edward M. Schaeffer, MD, PhD Professor of Urology and associate professor of urology, biochemistry, and molecular genetics at Northwestern University Feinberg School of Medicine in Chicago, Illinois, walks through the practical treatment timeline for enfortumab vedotin-ejfv (Padcev) plus pembrolizumab (Keytruda): Patients receive both drugs on day 1 and a single drug on day 8 of each 21-day cycle, repeating for 4 cycles, so the full neoadjuvant course runs about 12 weeks.

Meeks typically checks in with patients between cycles 2 and 3, both to confirm they're tolerating the regimen and to begin discussing the localized phase of care—including whether bladder preservation with surveillance might be an option—rather than raising that conversation too early, before patients are ready to process it.

On adverse events (AEs), Meeks notes that up to three-quarters of patients experience some AE, but most are manageable. Skin reactions affect approximately 14% of patients and are usually handled well by dermatology and medical oncology. Neuropathy is the toxicity patients worry about most, since it can interfere with fine motor tasks like buttoning clothes, and it's the AE most likely to trigger dose reductions or treatment discontinuation. Meeks says he sees neuropathy more often after surgery, during the adjuvant cycles, than in the neoadjuvant phase before surgery.

He also flags skin toxicity as a specific area requiring vigilance. Although dry skin, itching, and mild rash are common and respond to topical treatment, severe reactions—including bullous skin changes—occur in roughly 1 in 8 patients and warrant immediate referral to either the emergency department or dermatology. Meeks advises urologists to have that referral pathway already established before it's needed, rather than scrambling to find a dermatology contact once a severe reaction appears.

In the next episode, "Referral Pathways and Unmet Needs in Perioperative MIBC Care," Meeks closes the series by placing this regimen in the broader treatment landscape and offering concrete referral guidance for community urologists.