Treatment options for advanced urothelial cancer after progression on chemotherapy and immune checkpoint inhibitors: a literature review

Abstract

Objective: To describe the current treatment landscape in advanced urothelial cancer (aUC)/metastatic urothelial cancer and in particular to review the relevant literature highlighting recent advances in the treatment of patients with aUC after progression on chemotherapy and immune checkpoint inhibitor (ICI).Background: aUC is a very aggressive disease with poor outcomes. Over the past several years, its treatment landscape has seen significant advances with the approval of ICI and targeted agents, which have led to improved outcomes. The current standard of care for most patients with aUC involves platinumbased chemotherapy followed by ICI after progression or as switch maintenance therapy (if no progression after chemotherapy). Treatment of patients following progression on ICI is more challenging, but novel therapies have been approved, such as erdafitinib for tumors with fibroblast growth factor receptor 2 (FGFR2) or FGFR3 activating mutation or fusion (can also be used following progression on platinumbased chemotherapy), enfortumab vedotin (EV) and sacituzumab govitecan (SG) in an unselected patient population. Many other trials in this space are currently ongoing and other promising agents may also potentially become available in the future.Methods: Narrative overview of the recent literature relevant to the treatment of advanced/metastatic urothelial cancer following progression on chemotherapy and ICI was undertaken. Relevant literature was obtained from review of computerized databases including pubmed.gov and proceedings of major conferences including American Society of clinical Oncology (ASCO) Meetings, GU ASCO Symposia and European Society of Medical Oncology (ESMO) Meetings. Conclusion:In this narrative review, we highlight the current dynamic treatment landscape in aUC, emphasizing the recent important developments and a few examples of ongoing clinical trials. In particular, we focus on therapy options available following progression on platinum-based chemotherapy and ICI, a treatment space where until recently there had been no FDA-approved treatment options. The recent pivotal trials of antibody drug conjugates (ADCs) that led to FDA approvals in this space are highlighted, as are other agents currently in development. We conclude by discussing future directions and ongoing challenges in this evolving disease space.

Enfortumab vedotin as a salvage option as 5th line therapy for metastatic urothelial bladder cancer

“…Erdafitinib is a recently FDA-approved targeted therapy for patients with platinumrefractory mUC. Prerequisite is the proof of FGRF alterations, whereby only 15-20% of patients with mUC have susceptible FGFR alterations [16].…”

“…EV is an antibody-drug conjugate composed of an antibody targeting Nectin-4, and a potent microtubule disrupting chemotherapy agent MMAE. The interaction of EV with Nectin-4, which plays a role in cell adhesion, leads to the internalization of the antibody-drug conjugate into the tumor cell and release of MMAE, which results in tumor cell death [16]. Since a highly expression of Nectin-4 has been described in urothelial cancer cells, no pretherapeutic tissue analysis is necessary for utilizing EV [17,18].…”