Panel Discusses Unmet Needs in Advanced Urothelial Carcinoma

A roundtable discussion, moderated by Peter O’Donnell, MD, discussed the advanced urothelial treatment landscape, as well as recent trial data from ESMO 2023. Dr. O’Donnell was joined by Terence Friedlander, MD; Matthew Galsky, MD; and Jonathan Rosenberg, MD.

In the first segment of the roundtable series, the panel discussed continued unmet needs and challenges for patients with urothelial cancer.

Watch the next segment in this series.

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Dr. O’Donnell: We are filming this round table as part of the Uromigos Live event in November 2023, just about a week after ESMO finished up for this year. Let’s go back in time first, 2 weeks ago before we saw the ESMO data, and just to set the stage, what were the unmet needs in treating patients with urothelial cancer?

Dr. Friedlander: Just across the board, there are a lot of unmet needs. We need a cure for this disease, just to put it out there bluntly. That’s been a long ways coming, so I think in the frontline setting, we need better therapy. We need to prolong survival for patients with metastatic disease. I think getting patients into durable long-term remissions is really important, not just having marginal improvements in survival. I think in earlier-stage disease, there’s a lot of unmet needs as well. For muscle-invasive disease, cystectomy is a pretty awful thing that we do to patients, even though it can be curative for a lot of our patients. Better strategies to either improve outcomes after cystectomy or even to possibly avoid cystectomy. Then the non-muscle invasive space, we have patients who are in need of therapy if they’re BCG-refractory. There were some really interesting updates at ESMO in the non-muscle invasive space. A lot across the board.

Dr. O’Donnell: Thanks, Terry.

Dr. Galsky: Yeah, not much to add there. We need drugs that work better and that induce remissions that last longer.

Dr. Rosenberg: We still need treatments that are less toxic, even post-ESMO.

Dr. O’Donnell: Yeah, let me ask you, Jonathan, about that, because I think we have a biased view, we certainly do, at academic centers, with the kind of patients that make it to see us. In the community, I think treating bladder cancer is very different from a tolerability standpoint. Do you want to just comment on that and how critical that piece of it is in the decision?

Dr. Rosenberg: Depending on the patient profile, many of them have many different comorbidities that can impact treatment, and then the treatments themselves affect quality of life. Most oncologists in the community see only a handful of bladder cancer patients every year, and some may not have the experience dealing with some of the new agents and regimens, and some of the toxicities that occur can be quite daunting and occasionally really serious, or life-threatening, or even fatal. If someone has one of those, they’re not giving that therapy again unless there’s a lot of coaxing and help through that. I think there needs to be a lot of education around toxicity management with the newer approaches.

Dr. O’Donnell: I definitely will come back to that throughout the course of this time, thinking about how we manage some of the toxicities. Matt, maybe I’ll also ask you this just for setting the stage: We’ve seen some data about how much drop off there is, even for patients to get a therapy with metastatic urothelial cancer, and then how many patients don’t make it to a second line. It kind of sets up that idea of maybe how important that first choice is. Can you comment on that?

Dr. Galsky: Yeah, I certainly agree with that. Most real-world data suggests that only a subset of our patients, unfortunately, are able to receive treatment beyond the first line, because this is an aggressive disease. When it doesn’t respond to treatment, unfortunately it progresses rapidly most of the time. I do agree with the concept of putting one’s best foot forward in terms of treatment of this disease and trying to balance that with over-treatment, which probably rarely happens in the metastatic setting, but we’re still at risk for over-treating patients in that setting. Trying to devise regimens that can at least introduce a treatment-free period once we obtain that initial response.