What would Petros Grivas do?
This is a young man with very aggressive metastatic urothelial carcinoma of the bladder with liver & lung mets portending poor prognosis; comorbidities include diabetes mellitus with nephropathy (GFR 40 ml/min) and grade I neuropathy. Based on this low GFR it is difficult to use cisplatin-based chemotherapy, which would be ideal standard therapy.
Thus, options include clinical trial (preferably) or Gemcitabine/Carboplatin or pembrolizumab or atezolizumab. Tumor tissue has high PD-L1 status based on the companion diagnostic assay used with pembrolizumab. There is no available data yet comparing Gemcitabine/Carboplatin vs anti-PD-1/PD-L1 in tumors with high PD-L1 status, while randomized phase 3 trials are pending.
I would discuss with the patient the data by De Santis et al. [1] as well as those from Keynote 052 [2] and IMvigor210, cohort 1 trial [3], and other studies, and help him decide between options A and D.
I hope you can join us in Paris for BLADDR 2019 on 25-26 October to further discuss this and other interesting cases and clinical dilemmas. 1. De Santis M, et al. J Clin Oncol 2012;30:191-9.
2. Balar AV, et al. Lancet Oncol 2017;18:1483-92.
3. Balar AV, et al. Lancet 2017;389:67-76.