Dr Bellmunt on Enfortumab Vedotin/Pembrolizumab in the Community Setting for Urothelial Carcinoma

Joaquim Bellmunt, MD, PhD, associate professor, medicine, Harvard Medical School; director, Bladder Cancer Center, Genitourinary Oncology Program, Dana-Farber Cancer Institute, discusses the utility of treatment with enfortumab vedotin-ejfv (Padcev) plus pembrolizumab (Keytruda) for patients with locally advanced or metastatic urothelial carcinoma receiving care in the community setting.

For community oncologists considering the successful integration of enfortumab vedotin plus pembrolizumab into clinical practice, it's important to acknowledge varying levels of comfort and experience with different regimens, particularly in patients who may not be fit for carboplatin-based therapies, Bellmunt begins. Many community oncologists are familiar with using enfortumab vedotin plus pembrolizumab for patients who are unfit for carboplatin, driven by the awareness that carboplatin-based regimens may not yield optimal outcomes in the first-line setting, he explains. However, a certain level of hesitation persists in fully embracing enfortumab vedotin plus pembrolizumab due to its associated adverse effects (AEs), notably neuropathy, which demands specialized management expertise, Bellmunt notes. The nuances associated with this regimen require careful consideration, especially for oncologists who occasionally treat patients with bladder cancer and may lean toward choosing cisplatin-based therapies either as a primary option or in combination with maintenance therapy or immunotherapies, such as nivolumab (Opdivo), he elucidates.

In addition to insights gleaned from trials such as the phase 3 CheckMate-901 trial (NCT03036098), an unplanned analysis of patients from the phase 3 JAVELIN Bladder 100 trial (NCT02603432) sheds light on the effectiveness of maintenance avelumab (Bavencio) post-cisplatin-based therapy in locally advanced or metastatic urothelial cancer, Bellmunt continues. This analysis revealed that patients who received cisplatin-based therapy followed by maintenance avelumab achieved a higher median overall survival compared with those who received carboplatin prior to avelumab, he explains.

Despite the enduring confidence in cisplatin, there is a growing sentiment within the oncology community that enfortumab vedotin plus pembrolizumab may become more widely accepted and usedfor patients with bladder cancer, Bellmunt states. This shift is attributed to accumulating experience with using the agents and evolving perceptions regarding the regimen's efficacy and safety profiles, according to Bellmunt. As oncologists gain more familiarity and proficiency in managing the AEs associated with this regimen, the adoption of enfortumab vedotin plus pembrolizumab is likely to increase, he concludes.