The Evolving Landscape of UTUC Treatments and Patient Management With Dr. Jason Hafron

At the LUGPA 2024 Annual Meeting, Jason Hafron, MD, Michigan Institute of Urology, shares his perspective on the evolving landscape of upper tract urothelial carcinoma (UTUC) management, highlighting key trends and advancements for 2025. Building on recent data from the OLYMPUS trial and real-world evidence, Dr. Hafron discusses the increasing adoption of mitomycin for chemoablation and as an adjuvant therapy, as well as the growing emphasis on kidney-sparing approaches for low-risk patients.

Transcript 

Looking ahead to 2025, what emerging trends or advancements do you foresee in the diagnosis and management of upper tract urothelial carcinoma?

Dr. Hafron: I think in 2025, we’ll build on what’s changed recently in the last one to two years with the management of upper tract urothelial carcinoma. With the OLYMPUS trial and then the real-world evidence, we see that Jelmyto is being used as a chemoablative as well as an adjuvant agent in patients with upper tract urothelial carcinoma. So I think that adoption will continue, and I think as urologists we need to really restratify these patients. Identifying low risk patients that have low grade disease based on biopsy, have low grade cytology, and have tumors less than two centimeters, we should adopt a kidney-sparing approach, an endoscopic approach with the use of Jelmyto to spare these patients the morbidity of a radical nephroureterectomy.

What are your key takeaways from the LUGPA Annual Meeting so far, especially regarding UTUC treatment? 

Dr. Hafron: The key takeaways this year with UTUC are that Jelmyto can be used in the office. We’re seeing a lot of antegrade nephrostomy tube use for application of this. We’re seeing increased use of maintenance therapy. At the AUA last year, there was some very good data. It was small series, but that maintenance does have a benefit in patients that do respond to Jelmyto. We’re seeing a lot of that.

With the evolving landscape of UTUC treatments, how do you see the role of minimally invasive techniques, such as robotic surgery, changing in the coming years? 

Dr. Hafron: I think robotic surgery is here, and it’s going to continue to evolve. We’re seeing applications with single port radical robotic nephroureterectomies. I think that will continue to grow. I think that the use of a lymphadenectomy, and so within the guidelines, it’s recommended. I think that we need to use that more often in everyday practice. I think, again, going back to who’s the appropriate candidates, who needs surgery, who can be managed endoscopically, I think that’s where we have to focus on.

Immunotherapy has been a significant development in oncology. What are your thoughts on its current and future applications in UTUC treatment? 

Dr. Hafron: I think that unfortunately, UTUC is a small disease state. There’s not a tremendous amount of patients that suffer from this disease, but when you extrapolate what’s going on in the bladder, and especially advanced bladder cancer, we’re seeing significant innovation, significant application of immunotherapy. We can look at the NIAGARA trial, which just was released at ESMO recently. I mean, that was in bladder cancer, but if you extrapolate that to upper tract urothelial carcinoma, you can make an argument. So I mean, I think there’s no significant studies to have supported it, but I think, again, in bladder cancer, and usually we extrapolate bladder cancer to upper tract, we’re going to see more and more immunotherapies being applied.

What are the most promising research directions or clinical trials in UTUC that urologists should be aware of in 2025? 

Dr. Hafron: I think as a urologist, what I’m looking for is to see more data on maintenance therapy and the management of upper tract urothelial carcinoma with Jelmyto. I think, is there any biologic markers to predict responders? I think there’s a lot of opportunity for tumor sequencing, identifying who will respond to what therapy. I think there’s a lot of opportunity there to help better manage these patients.