ESMO 2025 | Novel strategies for the management of metastatic urothelial cancer
Enrique Grande, MD, MD Anderson Cancer Center Madrid, Madrid, Spain, discusses the current first-line treatment options for metastatic urothelial cancer, highlighting the combination of enfortumab vedotin and pembrolizumab as the preferred choice, with platinum-based chemotherapy and PD-1 or PD-L1 inhibitors as alternatives. Tailoring treatment according to patient biomarkers and clinical profiles is still important, and for patients progressing on enfortumab vedotin and pembrolizumab, platinum-based chemotherapy and targeted agents such as FGFR inhibitors and trastuzumab deruxtecan may be considered. This interview took place at the European Society for Medical Oncology (ESMO) 2025 Congress in Berlin, Germany.
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Transcript
Major guidelines across the world, ESMO guidelines, NCCN guidelines, and others, are consistently recommending for the first-line treatment of metastatic urothelial cancer, the combination of Enfortumab vedotin and Pembrolizumab. And only if this combination is not suitable, or it is contraindicated, or simply this is not available because of access or reimbursement, this is when platinum-based chemotherapy still has a role by using the triplet gemcitabine, cisplatin, and nivolumab or by using gemcitabine, cisplatin, or gemcitabine, carboplatin for avelumab maintenance in those patients with initial benefit, but don’t forget that we have also the opportunity to give PD-1 or PD-L1 inhibitors, Pembrolizumab or Atezolizumab, for those patients ineligible to receive any platinum...
Major guidelines across the world, ESMO guidelines, NCCN guidelines, and others, are consistently recommending for the first-line treatment of metastatic urothelial cancer, the combination of Enfortumab vedotin and Pembrolizumab. And only if this combination is not suitable, or it is contraindicated, or simply this is not available because of access or reimbursement, this is when platinum-based chemotherapy still has a role by using the triplet gemcitabine, cisplatin, and nivolumab or by using gemcitabine, cisplatin, or gemcitabine, carboplatin for avelumab maintenance in those patients with initial benefit, but don’t forget that we have also the opportunity to give PD-1 or PD-L1 inhibitors, Pembrolizumab or Atezolizumab, for those patients ineligible to receive any platinum. At the end, we need to tailor the treatment according to biomarkers, maybe not in the first line, but according to the clinical profile of the patients because of the expected toxicities that we may have. For those patients that are progressing to Enfortumab vedotin-Pembrolizumab, maybe the standard of care right now would be considered platinum-based chemotherapy. But don’t forget that we have also targeted agents. The first one, FGFR inhibitors like Erdafitinib, for those 7 to 15% of the patients that have positive alterations, mutations, fusions affecting the gene of FGFR3. And also, we have the opportunity to offer Trastuzumab deruxtecan for those patients with overexpression of HER2 based on the very good response data, but unfortunately, we don’t have an impact on overall survival, we don’t have randomized data in this field, we need to wait for more and longer follow-up of the ongoing trials.
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