Shilpa Gupta, MD: Welcome to this OncLive Peer Exchange®, “Advances in the Treatment of Urothelial Carcinomas.” I’m joined by my esteemed colleagues and friends. I’ll let them introduce themselves. I’m Dr Shilpa Gupta. I’m a genitourinary [GU] medical oncologist at the Cleveland Clinic in Ohio, and I’m delighted to be joined by Dr Andrea Apolo, Dr Petros Grivas, and Dr Mamta Parikh. Dr Apolo, would you please introduce yourself?

Andrea B. Apolo, MD: My name is Andrea Apolo. I’m a geomedical oncologist at the National Cancer Institute in Bethesda, Maryland.

Petros Grivas, MD, PhD: I’m Petros Grivas. I’m a medical oncologist serving as a clinical director of the GU Cancer Program at the University of Washington Fred Hutchinson Cancer Center in Seattle.

Mamta Parikh, MD, MS: I’m Mamta Parikh. I’m a genitourinary medical oncologist at the UC Davis Comprehensive Cancer Center in Sacramento, California.

Shilpa Gupta, MD: Andrea would you like to give us a brief overview of urothelial carcinomas and what stages you are involved with in general in your practice?

Andrea B. Apolo, MD: I predominantly see patients with advanced metastatic disease who are receiving second-line, third-line, and beyond therapy, but of course we also see patients who are receiving first-line therapy. We see patients with muscle-invasive bladder cancer as well. We have a multidisciplinary clinic where we discuss patients in terms of neoadjuvant trimodality approaches and adjuvant therapy. And more and more we’re seeing patients with non–muscle-invasive bladder cancer [NMIBC] to discuss systemic therapies.

Shilpa Gupta, MD: Petros, what about you?

Petros Grivas, MD, PhD: We have an academic center, a tertiary referral for many practices, and we see patients across the spectrum of bladder cancer. Of course, we are starting to see patients more and more with BCG-unresponsive non–muscle-invasive bladder cancer. We see quite a bit in muscle-based bladder cancer. We have a multidisciplinary clinic where we see patients with muscle-invasive disease localized, along with radon, medon, and urological oncology, to make multiple decisions for bladder preservation and beyond. And of course, we see many patients with metastatic disease across the different lines of therapy, and we have multiple clinical trials where we try to enroll patients.

Shilpa Gupta, MD: Mamta, how’s your practice for the management of urothelial cancer?

Mamta Parikh, MD, MS: I am also at an academic center, so we do get tertiary referrals, but we work very closely with our urologist. Like Andrea and Petros, we are starting to see more and more patients with non–muscle-invasive bladder cancer, though they’re still more of a minority of the patients whom I see. We see a fair number of patients with muscle-invasive bladder cancer, though primarily we see metastatic disease. I see about 20% upper tract tumors as well in my practice.

Shilpa Gupta, MD: It sounds like more and more you’re involved with muscle-invasive and metastatic disease, but you’re starting to see a lot of patients with non–muscle-invasive bladder cancer for trials. Andrea, do you see a lot of referrals for use of pembrolizumab in non–muscle-invasive bladder cancer?

Andrea B. Apolo, MD: I do. So pembrolizumab is now FDA [Food and Drug Administration] approved for patients with BCG-refractory disease who either cannot undergo a cystectomy or refuse to undergo a cystectomy. And I’m seeing more and more patients wanting to get this therapy as an option, so they don’t undergo a radical cystectomy in the non–muscle-invasive setting.

Shilpa Gupta, MD: Petros, in your institution, are the urologists funneling these patients to you? Are patients learning about this option and coming to you directly if they’ve been offered a cystectomy?

Petros Grivas, MD, PhD: We have a very tight and close relationship with our urologist. And we have many patients who are seen by our urology colleagues, and they are being treated with intravesical therapies, commonly BCG or chemotherapy depending on the case. And if these patients develop BCG-unresponsive disease, radical cystectomy is a commonly preferred option, but many patients either decline that option or are not fit enough or are frail to undergo cystectomy. Those patients may be seeing the multidisciplinary clinic to discuss intravesical or systemic options. And as Andrea said, intravesical pembrolizumab is an FDA-approved option for BCG-unresponsive disease in patients who cannot undergo or decline radical cystectomy. So we see a few of those patients and patients who are about to go to clinical trials that make and combine or include both intravesical and systemic therapy options.

Shilpa Gupta, MD: Mamta, in your practice, what percent of patients have de novo metastatic disease? Could you give us a breakdown of patients with localized disease vs patients with de novo metastatic disease in your practice?

Mamta Parikh, MD, MS: De novo metastatic disease probably makes up about 40% of my practice. Maybe 10% of patients had a more localized disease that then progressed to metastatic, and then the remainder of those patients are either second- or third-line referrals or have muscle-invasive or non–muscle-invasive disease.

Shilpa Gupta, MD: Andrea, for you? How many patients have de novo metastatic disease?

Andrea B. Apolo, MD: About half of the patients are presenting with metastatic disease. This is a bit of a skewed view because I do see more metastatic disease, but naturally, patients go through muscle-invasive disease and then develop metastatic disease. But we see a lot of de novo metastatic disease within our practice, and I’m counting patients with local lymph node disease and muscle-invasive disease whom we offer curative intent treatment with systemic therapy and surgery if appropriate.

Shilpa Gupta, MD: Petros, is that the case for your practice too?

Petros Grivas, MD, PhD: I agree with Andrea and Mamta. There is a mixture of different patient populations, and this may be evolving over time, but traditionally there was a higher proportion of patients with metastatic disease. But now with our established multidisciplinary bladder cancer clinic we have every Tuesday morning, we see our patients with localized muscle-invasive disease, and that’s a wonderful one-stop shop for our patients. As I mentioned before, they see the urologist, medon, radon pathology. Radiology is helping us review those scans and images. And this has taken a significant portion of my patient population, and a smaller proportion right now are patients with BCG-unresponsive NMIBC. That’s probably the smallest population, but things are changing as medical oncologists are involved earlier and earlier in this disease space.

Transcript edited for clarity.