New Bladder Cancer Regimens Reshape Treatment Across Disease Stages

In an interview with Pharmacy Times, Robin Tumlinson, PharmD, BCOP, clinical pharmacist specialist in genitourinary oncology at Vanderbilt University Medical Center, discussed recent developments reshaping bladder cancer treatment across disease stages. Tumlinson highlighted the movement of enfortumab vedotin (Padcev; Astellas Pharma) plus pembrolizumab (Keytruda; Merck), commonly referred to as EV plus pembrolizumab, into frontline metastatic and perioperative settings, as well as the growing incorporation of immunotherapy into treatment for muscle-invasive bladder cancer.

According to Tumlinson, these developments have improved outcomes but introduced new complexities for treatment teams. Clinicians must become familiar with different dosing approaches and toxicity profiles while coordinating care more closely between urology and medical oncology. This coordination has become particularly important as perioperative strategies bring medical oncologists into the care of patients with earlier-stage disease.

Tumlinson also addressed treatment decisions for patients with non–muscle-invasive bladder cancer, including when bladder-preserving treatment may remain appropriate and when radical cystectomy should be considered. Although cystectomy or clinical trial participation remains preferred for many patients with bacillus Calmette-Guérin (BCG)–unresponsive disease, treatment decisions may be influenced by age, performance status, comorbidities, surgical eligibility, and patient preferences.

Newer options, including nadofaragene firadenovec-vncg (Adstiladrin; Ferring Pharmaceuticals), nogapendekin alfa inbakicept-pmln (Anktiva; ImmunityBio) plus BCG, and the gemcitabine intravesical system (Inlexzo; Johnson & Johnson), have expanded bladder-preserving approaches. However, differences in institutional availability, administration, and dosing schedules may affect treatment selection.

In advanced urothelial carcinoma, Tumlinson emphasized the importance of close monitoring and timely dose modification with EV plus pembrolizumab. As antibody-drug conjugates and immunotherapies move into earlier settings, unresolved questions surrounding treatment sequencing and long-term adverse-event management will require continued multidisciplinary collaboration.