Can my father benefit from immunotherapy for bladder cancer?

Question

Hello doctor,

My 63-year-old father’s bladder cancer has spread to his liver despite initial chemotherapy. The doctor suggested immunotherapy, but we are not sure which drug is best or what side effects to expect.

Could you explain how response rates differ between immunotherapy and chemotherapy and what supportive care helps maintain quality of life?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I am sorry your family is dealing with this.

Assuming this is metastatic urothelial carcinoma and the initial chemotherapy was a platinum regimen such as Cisplatin or Gemcitabine or Carboplatin/Gemcitabine, then Pembrolizumab is usually the checkpoint inhibitor with the strongest evidence after platinum failure. Current guidance says that after prior platinum-based chemotherapy, if there has been no prior checkpoint inhibitor, the patient should be offered Pembrolizumab.

In a well-known clinical trial, Pembrolizumab outperformed salvage chemotherapy in this exact post-platinum setting. The trade-off is that most patients still do not respond, so it is not a guaranteed benefit; however, when Pembrolizumab works, responses are often more durable, and patient-reported quality of life is stable or improved more often than with chemotherapy.

On side effects, immunotherapy is often easier day to day than chemotherapy, but it has a different risk profile. Treatment-related adverse events are lower with Pembrolizumab than with chemotherapy, around 16.5 % vs. 50.2 %.

Common side effects include fatigue, rash or itching, diarrhea, nausea, decreased appetite, and constipation. The important serious risks are immune-related inflammation of organs such as the lungs, colon, liver, thyroid or pituitary or adrenal glands, kidneys, heart, skin, and nerves, and these need prompt reporting because they are very treatable when recognized early.

So, when families ask me which drug is best, my practical answer is:

Among checkpoint inhibitors, Pembrolizumab is usually the best-supported choice here.

I would like some details that would help narrow this further, which are:

1. What chemotherapy did he get, and did the cancer grow during chemo or after finishing it?

2. Has he had any prior Avelumab or other immunotherapy?

3. What is his current performance status and liver function?

4. Has the tumor been tested for FGFR2/3 (fibroblast growth factor receptor 2 and 3) alterations?

5. Does he have any autoimmune disease or need chronic steroids?

If you send these details, I can probably give a more definitive opinion.

Best wishes