Avelumab Maintenance Makes a Mark on the Bladder Cancer Treatment Paradigm

Avelumab (Bavencio) maintenance is the current standard of care, barring contraindication, for the treatment of patients with locally advanced or metastatic urothelial carcinoma that has not progressed with frontline platinum-based chemotherapy, explained Robert Dreicer, MD, who added that it is too early to tell whether the approach will remain a pillar of care for the unforeseeable future.

“This is a very rapidly moving field, which is exciting. I wouldn’t necessarily say that this is how we’re going to [treat patients] forever. It’s the standard of care now, but a lot of other things may inform how we manage patients going forward over the next couple of years,” said Dreicer.

“The larger issue is whether or not other developments may occur over the next couple of years, including data that were presented at the 2021 Genitourinary Cancers Symposium where adjuvant nivolumab [Opdivo] moved the needle in terms of disease-free survival. There are other checkpoint inhibitor combinations that are being tested in the frontline setting. Therefore, any of those developments can perturb the potential of using maintenance therapy.”

In an interview with OncLive^® during an Institutional Perspectives in Cancer webinar on genitourinary malignancies, Dreicer, deputy director, UVA Cancer Center, director, Solid Tumor Oncology in the Division of Hematology/Oncology, and a professor of medicine and urology, University of Virginia Health System, discussed the optimal use of checkpoint inhibitors in urothelial carcinoma. 

OncLive^®: Are checkpoint inhibitors the standard of care for patients who are ineligible for frontline chemotherapy? 

Dreicer: Patients who are truly not fit at all for chemotherapy represent a very poor prognostic group. In the setting where you can administer carboplatin, some of those patients may be candidates for checkpoint inhibitors, but many patients really need to be approached with best supportive care. [I would recommend] checkpoint inhibitors if you can give them. Otherwise, symptomatic supportive care seems most appropriate.

Could the combination regimens that were evaluated in the KEYNOTE-052 and IMvigor130 trials play a role in practice despite their findings?

Those two large trials, which were both well done, asked whether giving combinatorial therapy with a checkpoint inhibitor and chemotherapy improves outcomes. Unfortunately, both studies were essentially negative. They didn’t show that there was any improvement in survival, although there was a little bit of progression-free survival benefit in the IMvigor130 trial. The reality is that it didn’t move the needle, and combinatorial therapy, at least up front as those trials were designed, is not going to really move forward.

What was significant about the findings from the JAVELIN Bladder 100 trial?

Given the fact that progress in urothelial cancer has been, although somewhat increased in the past couple of years with checkpoint inhibitors and some other novel therapies that have been developed, people still do poorly. JAVELIN Bladder 100 showed that people who got chemotherapy, either carboplatin or cisplatin-based chemotherapy who achieved at least stable disease or better and then subsequently received maintenance avelumab, had a significant improvement in survival compared with the standard of care, which was observation until progression. [The study] moved the needle. It may not be the standard of care, but it was an important trial, and it affects the clinical management of patients today.

Is avelumab the standard of care for all patients who respond or experience stable disease on induction chemotherapy?

In the absence of some contraindication, if patients meet the criteria for JAVELIN Bladder 100, after receiving platinum-based chemotherapy, it is a standard approach to offer patients this therapy. To not discuss it or not consider it, frankly, would be less than optimal patient management in 2021.