Should I continue immunotherapy or start Enfortumab Vedotin?

Question

Hello doctor,

I am a 62-year-old man currently undergoing treatment for metastatic urothelial carcinoma of the bladder. I have completed three cycles of immunotherapy with Pembrolizumab, and my recent PET-CT scan shows mild liver involvement. Over the past few weeks, I have been experiencing severe fatigue, and recent blood tests have also shown mild anemia.

Given these findings, I would like to understand:

Should my treatment be continued with immunotherapy?
Is it advisable to switch to Enfortumab Vedotin at this stage?

Kindly advise on the best next step in management and whether my current symptoms could be related to disease progression or treatment-related side effects.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

Thank you for reaching out and sharing your concerns so clearly.

After completing three cycles of Pembrolizumab, it is still too early to say for sure that the treatment is not working, especially since the PET-CT (positron emission tomography-computed tomography) scan shows only mild liver involvement (meaning a small or limited spread to the liver).

If you have the detailed scan report, please feel free to share it, as I would like to review whether this could represent pseudoprogression. Pseudoprogression is a situation sometimes seen with immunotherapy, where scans may temporarily look worse because immune cells are attacking the cancer, causing inflammation. This can mimic tumor growth on imaging before actual improvement occurs.

Your fatigue and mild anemia (a slightly low red blood cell count, which can cause tiredness) are quite common and can be related to:

The cancer itself.
Immunotherapy side effects. Immunotherapy is a type of cancer treatment that helps your own immune system recognize and attack cancer cells.
Nutritional deficiencies.

These symptoms do not automatically mean the treatment is failing, but they do require close monitoring and supportive care.

At this stage, the usual and evidence-based approach would be:

Continue Pembrolizumab for now.
Repeat imaging after two to three more cycles to better assess the true treatment response.
Closely monitor blood counts, liver function tests, and symptoms.

If future scans show clear disease progression, such as increasing liver involvement, along with worsening symptoms or overall clinical decline, then it would be appropriate to discuss switching treatment with your medical oncologist.

One such option at that point could be Enfortumab Vedotin, which is a targeted therapy designed to attack bladder cancer cells more directly. Kindly consult your doctor and take medicines accordingly.

Please let me know if your fatigue worsens or if you develop any new symptoms such as:

Yellowing of the eyes or skin (jaundice).
Persistent pain.
Unexplained weight loss.

We will continue to take this step by step, with careful monitoring and the best evidence-based decisions tailored specifically for you.

I hope this helps.

Please revert in case of further queries.

Thank you.