{"version":1,"type":"rich","provider_name":"Libsyn","provider_url":"https:\/\/www.libsyn.com","height":90,"width":600,"title":"Advanced bladder cancer: Dr. Arjun Balar talks treatment strategies in a changing field","description":"Systemic treatment for advanced urothelial cancer is quickly evolving. On this week\u2019s podcast, Arjun Balar, MD, director of the genitourinary medical oncology program at New York University discusses his approach amid changing times with guest host Alan Lyss, MD, a community-based medical oncologist and clinical researcher in the St. Louis area before his recent retirement.  Chemotherapy or immunotherapy first line? With the negative phase 3 results for chemotherapy in combination with either pembrolizumab or atezolizumab, \u201cif I use immunotherapy, I use it alone,\u201d Dr. Balar said. Patients who need \u201ca response right away\u201d for aggressive disease get chemotherapy. In general, first-line chemotherapy \u201cprobably is the better route for a lot of people,\u201d he said. There is a role for immunotherapy in the first line when chemotherapy can\u2019t be tolerated because of age or other reasons, and in the second line, immunotherapy is standard of care. PD-1\/PD-LI expression is too inconsistent to help guide the decision. It\u2019s based instead on clinical judgement, given patient and disease characteristics. Antibody-drug conjugates The class includes enfortumab vedotin and sacituzumab govitecan, both approved for third-line treatment after chemo and immunotherapy. Essentially, they are homing molecules targeting cancer-specific antigens coupled with a potent cytotoxic payload. They have strong potential in combination with immunotherapy. \u201cI think, in the next 3-5 years, we're going to find ADCs plus immunotherapy become the new standard of care,\u201d Dr. Balar said. New enfortumab vedotin data show activity in the second line among medically frail patients ineligible for chemotherapy who were treated instead with immunotherapy for metastatic disease. \u201cThis drug can potentially rescue those patients as an option after immunotherapy,\u201d said Dr. Balar, an enfortumab vedotin investigator. Next-generation sequencing There\u2019s no role yet for sequencing in the first line, but it\u2019s necessary in later lines to check eligibility for drugs aimed at specific mutations, such as the tyrosine kinase inhibitor erdafitinib for patients with susceptible FGFR3 or FGFR2 genetic alterations. Assays are available commercially from Foundation and other companies. Results can take up to 6 weeks, so \u201cI do it early on. I know that information is potentially going to be useful in making treatment decisions,\u201d Dr. Balar said. Enfortumabe vedotin adverse events Side effects can include hyperglycemia within the first one or two cycles. Sometimes it\u2019s asymptomatic, sometimes it\u2019s accompanied by acid-base disturbances, and in very rare cases, it\u2019s fatal. The problem is possibly linked to higher baseline body mass index. At least half of patients develop a sunburn-like rash, also within the first one or two cycles, that spares the face and can be pruritic. It\u2019s manageable by topical steroids, oral antihistamines, dose reductions, or dose interruptions. \u201cIf anything severe is going to happen, it's going to happen within the first one or two cycles. I see [patients at] every visit\u201d in the first two cycles \u201cprimarily to catch anything untoward,\u201d Dr. Balar said. Neuropathy is the \u201cmost significant dose-limiting toxicity, and tends to develop about 4 months into treatment,\u201d he said. Show notes written by M. Alexander Otto. Dr. Balar disclosed research, advisory, and\/or speaker relationships with Genentech, Incyte, Bristol-Myers Squibb, Janssen, Merck, Pfizer, AstraZeneca, and other companies. Dr. Lyss writes a column for MDedge Hematology\/Oncology called \u201cClinical Insights\u201d and had no other conflicts of interest. ","author_name":"Blood & Cancer","author_url":"https:\/\/www.mdedge.com\/podcasts\/blood-cancer","html":"