A roundtable discussion, moderated by Vadim Koshkin, MD, of the University of California, San Francisco, focused on treatment selection for different patient populations with advanced bladder cancer, including a discussion of new data presented at ASCO 2023. Dr. Koshkin was joined by a panel that included Matthew Zibelman, MD; Cora Sternberg, MD; and Daniel Petrylak, MD.
In the next segment of the roundtable series, the panel discusses the approach to treating patients with platinum-ineligible bladder cancer.
Dr. Koshkin: For a patient population that’s not eligible for any platinum-based therapy, so usually with significant renal dysfunction, for instance, like a dialysis patient, Cora, you mentioned. What is your frontline treatment at this point? Or how do you approach such patients? Do you see a lot of those patients?
Dr. Sternberg: I usually give them immunotherapy. We published the SAUL study, and we have a poster updating it here at this ASCO  in which we allowed patients with inflammatory disease and patients with poor creatinine clearance, patients on dialysis, patients who generally were not eligible for any of the registration trials. We found that the results were pretty much similar to those in the registration trials. The ones who did the worst were the ones with brain metastases and the ones with PS [Performance Status] of 2. Again, PS of 2 is something subjective. I would imagine that in many countries, they didn’t have anything to do. Maybe this was PS 3. It’s very subjective. But those were the 2 groups of patients who did the worst. The ones who really did the best were the ones who had inflammatory disease, which gives me a lot of courage because I have these patients with colitis, which you normally wouldn’t put them on immunotherapy, but now I have the courage to do that, and I have, working with their gastroenterologist or working with their other pulmonologist, have not had problems giving immunotherapy to patients with inflammatory disease.
Dr. Koshkin: Is there still a large patient population you do give just checkpoint monotherapy to, in a frontline setting?
Dr. Sternberg: Well, I was until just now when the pembrolizumab/enfortumab vedotin (EV) was just approved a few weeks ago. But I was giving patients coming in with comorbidities, elderly patients, poor performance status, we had patients in the 80s and 90s coming into Weill Cornell and want to be treated.
Dr. Koshkin: You would consider those patients for enfortumab/pembrolizumab now?
Dr. Sternberg: Yeah. I would, now.
Dr. Koshkin: Okay. Is that the consensus?
Dr. Zibelman: Yeah, I think for most patients, I think that would be what I would offer them. If there were potential comorbidities, really bad neuropathy, maybe you would think about pembrolizumab alone. But I think for most, I think that would make sense.
Dr. Petrylak: There are few patients who are truly platinum-ineligible, very few. You can count them on 1 hand, basically.
Dr. Koshkin: Yeah, so it is a limited population, but it sounds like even to this population that EV/pembrolizumab data, we can extrapolate.
Dr. Zibelman: Especially if some of their problem is related to the disease. If their performance status is low because of symptoms related to the disease that you can potentially improve with good systemic therapy, I think obviously that’s worth trying.