Metastatic Urothelial CUA-GUMOC 2019 + updates Flashcards
What are eligibility criteria for cisplatin based chemotherapy?
GFR>59, ECOG<2, absence of hearing loss>grade1, absence of neuropathy > grade 1, absence of NYHA heart failure> II
who is a candidate for split dose cisplatin?
GFR 45-60, ECOG 2 performance status
What are the first line option systemic therapies
gem-Cis, or dose dense MVAC( methotrexate, vinblastine, doxorubicin, cyclophosphomide) with growth factor support for patients where more aggressive treatment is desired
Is GC equal to MVAC? if so why do GC?
yes it is, complications such as neutropenic sepsis, toxic death, mucositis much higher with MVAC
what are the options in patients ineligible for cisplatin based chemo?
Gem-carbo, If ineligible for combination then single agent gem, paclitaxel or docetaxel is recommended
What are immunetherapy options in first line setting cisplatin ineligible patients( the GL is outdated), as per new capmbell what are the options?
GL says no, perhaps there is no canadian approval, I am not sure. but campbell says pembro or atezolizumab are options in this setting.
anti-PD-L1 agents atezolizumab, durvalumab, and
avelumab received approval in patients with metastatic urothelial cancer previously treated with platinum-based chemotherapy(also approved by HC). The anti-PD-1 agents pembrolizumab(approved by HC) and nivolumab received approval in patients with metastatic urothelial cancer previously treated with platinum-based chemotherapy
Is pembro recommended in disease progression during or after cisplatin based chemo?
YES( this was keynote045, pembro vs dealer’s choice) , if pembro not available can try docetaxel or placitaxel. re-treatment with cisplatin also reasonable in patients who have had prolonged response to cis( 6-12 months)
Should PD-L1 testing be done to choose who gets immunotherapy in the second line?
NO, GL says so
what should be the management of a patient with cT4b or cN1-N3?
GU DSG: 4-6 cycles of cisplatin based chemo( first line systemic chemo)
If good response: consolidation with RC+PLND or XRT
THIS disease can be cured in well selected patients
what are two situations in which HDRT(+/-chemo) is preferred to RC+PLND in T4b orCn1,n3 disease following induction chemo?
t4b disease that does not downstage and surgical resection is often not feasible, N3 disease that is persistent( this would be an aggressive disease and HDRT represents a less invasive option)
Is metastetectomy/ HDRT to bladder recommended in metastatic bladder ca?
generally NO, DSG discussion needed
Does addition of atezolizumab to GC prolonged PFS in patients with metastatic UC in first line?
YES, straight from IMvigor 130 : Addition of atezolizumab to platinum-based chemotherapy as first-line treatment prolonged progression-free survival in patients with metastatic urothelial carcinoma
What is the role of Avelumab in first line setting for metastatic urothelial cancer?
Maintenance avelumab plus best supportive care significantly prolonged overall survival, as compared with best supportive care alone, among patients with urothelial cancer who had disease that had not progressed with first-line chemotherapy. (Javellin Bladder 100)
