Utilization of systemic therapy for treatment of advanced urothelial carcinoma: Lessons from real world experience.
Utilization of systemic therapy for treatment of advanced urothelial carcinoma: Lessons from real world experience.
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DOI：
10.1016/j.ctarc.2021.100325
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发表时间：
2021-01-01
影响因子：
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通讯作者：
Agarwal, Neeraj
中科院分区：
文献类型：
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作者：
Swami, Umang;Grivas, Petros;Agarwal, Neeraj
转移性膀胱癌的总生存率很低。虽然全身治疗可以提高总生存率，但现实世界的研究表明，超过一半的患者没有接受任何全身治疗，而只有约15-20%的患者接受二线治疗。即使在接受全身治疗的患者中，也观察到卡铂在一线的不成比例的高使用，尽管顺铂的上级有效性已被证明。这些观察结果的原因包括铂类化疗方案的中等有效性和相对毒性、对这一主要老年患者人群的体能状态和合并症的担忧、沟通障碍、缺乏社会支持以及获得负担得起的医疗保健。在本文中，我们讨论了克服这些挑战的潜在方法，包括（1）通过最大限度地接受基于顺铂的新辅助治疗来预防/延迟转移性疾病，并开发耐受性更好和更有效的新辅助和辅助治疗，（2）在4-6个周期的基于铂的化疗后使用avelumab维持治疗，以克服患者从一线治疗到二线治疗的流失，（3）将有效且耐受性良好的全身性疗法（如恩福妥单抗vedotin和erdafitinib）推进至一线转移性环境或甚至局部环境，（4）进一步开发有效且耐受性良好的疗法（如新型抗体-药物缀合物sacituzumab govitecan），和（5）改善全身性治疗剂的可负担性和可获得性。
Metastatic bladder cancer has poor overall survival. Though systemic therapies have shown to improve overall survival, real-world studies have shown that more than half of the patients do not receive any systemic therapy, while only around 15-20% receive second-line therapy. Even in patients receiving systemic therapies a disproportionately higher use of carboplatin is observed in the first line despite proven superior effectiveness of cisplatin. Reasons for these observations include moderate effectiveness and relatively toxicity of platinum-based chemotherapy regimens, concerns with performance status and co-morbidities in this predominantly older patient population, communications barriers, lack of social support, and access to affordable healthcare. Herein we discuss potential ways to overcome these challenges which include (1) preventing/delaying metastatic disease by maximizing the receipt of neoadjuvant cisplatin-based therapy, and development of better tolerated and more effective neoadjuvant and adjuvant therapies, (2) use of avelumab maintenance therapy after 4-6 cycles of platinum-based chemotherapy to overcome attrition of patients from first to second-line therapy, (3) advancing effective and well-tolerated systemic therapies such as enfortumab vedotin, and erdafitinib to the first-line metastatic setting or even to the localized setting, (4) further development of effective and well-tolerated therapies like sacituzumab govitecan, a novel antibody-drug conjugate and (5) improving affordability and accessibility to systemic therapy agents.