Personalized Oncology: Dr. Karine Tawagi Discusses the Future of Bladder Cancer Treatment Decision-Making With ctDNA

In the fourth panel of the Advancements in Oncology event, held on Saturday, June 1, The Oncology Brothers, Rahul Gosain, MD, MBA, and Rohit Gosain, MD, sat down with Karine Tawagi, MD, of the University of Illinois Chicago, to discuss genitourinary cancer-related data from the 2024 American Society of Clinical Oncology Annual Meeting.

Dr. Rahul Gosain emphasized the potential bladder cancer paradigm shift in patient-reported outcomes emerging from EV-302, particularly at lower doses where improved tolerability is observed alongside favorable patient outcomes. This prompted a key consideration: How can clinical tools like circulating tumor DNA (ctDNA) inform treatment adjustments and transitions?

ctDNA Applicability, Efficacy

Dr. Tawagi shed light on the evolving landscape, citing insights from studies like KEYNOTE-361 and recent presentations on metastatic urothelial settings. “Researchers found that there was ctDNA clearance much quicker for chemotherapy than for immunotherapy,” she noted.

While acknowledging limitations in data specific to the enfortumab vedotin (EV)/pembrolizumab context, the integration of ctDNA into clinical practice was discussed. Dr. Tawagi detailed her approach, stating, “I am ordering ctDNA tests, not based on any cadence, per se, but every 3 to 6 weeks.”

The conversation delved into practical considerations, with Dr. Tawagi detailing her approach to ordering ctDNA assessments at regular intervals. “If someone has toxicity or they want to break from EV, I may be looking at the ctDNA in addition to their every-3-month imaging to help me feel more confident about holding the dose,” she emphasized.

Quality of life emerged as a key consideration, particularly for metastatic patients experiencing complete responses. Dr. Rohit Gosain highlighted patient sentiments: “They say, ‘Doc, just do not stop treatment. Just let it go.’“

Second-Line Therapy and Beyond

Looking ahead, Dr. Rohit Gosain underscored the importance of considering next steps post-EV/pembrolizumab, emphasizing the significance of genomic profiling and the exploration of alternative therapies like erdafitinib and sacituzumab govitecan.

Toxicity management emerged as a central theme, with a focus on adverse events like neutropenia and diarrhea associated with sacituzumab govitecan. “The use of primary granulocyte colony-stimulating factor prophylaxis is extremely important with this regimen,” according to Dr. Tawagi.

The conversation concluded with an acknowledgment of the unfortunate mortality associated with treatment-related complications, underscoring the ongoing challenges of balancing therapeutic benefits with potential risks in advanced bladder cancer care.

View the next segment of this session: Prostate Cancer Management in Focus: Dr. Karine Tawagi’s Thoughts on ¹⁷⁷Lu-PSMA-617.