Dr Bilusic on Updates to the Urothelial Carcinoma Treatment Armamentarium

Marijo Bilusic, MD, PhD, medical oncologist, Genitourinary Medical Oncology, University of Miami Health System, Sylvester Comprehensive Cancer Center, discusses updates seen in the treatment armamentarium for patients with urothelial carcinoma, as presented at the 2023 Sylvester Annual Oncology Updates Meeting.

Numerous topics were covered during the event, which primarily focused on the phase 3 VESPER trial (NCT01812369), Bilusic begins. This trial involved a comparison between 2 chemotherapy regimens, 6 cycles of high-dose MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) vs 4 cycles of gemcitabine/cisplatin, in patients with locally advanced bladder cancer, he says. The initial findings from this trial, which were published in 2020, yielded a positive outcome with high-dose MVAC. However, the significant development with this trial in 2023 was the report of the 5-year overall survival (OS) data, which revealed an improvement in OS rates with MVAC vs gemcitabine plus cisplatin, Bilusic explains. These findings demonstrated the importance of delivering more cisplatin-based chemotherapy, as opposed to less, in patients with locally advanced bladder cancer, he notes. 

Both regimens used in VEPSER are cisplatin-based, Bilusic expands. It is important to recognize that the VESPER data likely indicate the benefit of higher cisplatin doses, rather than a benefit of MVAC over gemcitabine plus cisplatin, he adds. Notably, approximately 80% of patients in the MVAC arm could not complete all 6 cycles of treatment because of treatment-related toxicity, a vital point to consider when discussing chemotherapy options with patients, he emphasizes. Prior to this trial, the treatment recommendation for patients with locally advanced urothelial carcinoma was 3 to 4 cycles of chemotherapy. However, the VESPER data indicate that a more extended treatment duration is advisable, Bilusic explains. This shift in recommendation is a central message that was conveyed during the Sylvester Annual Oncology Updates Meeting.

A notable number of patients who received 6 cycles of chemotherapy died within the 5-year survival timeframe, a result that fell short of desired outcomes, Bilusic continues. The findings from VESPER and other trials emphasize the need for a critical reevaluation of bladder cancer treatment strategies, specifically concerning the delivery of cisplatin-based chemotherapy, Bilusic adds. The lessons learned from bladder cancer research will guide discussions with patients and inform decision-making processes as clinicians continue to aim for improved survival rates and better patient outcomes, Bilusic concludes.