Updated SITC Immunotherapy Guidelines for Urothelial Cancer

The Society for Immunotherapy of Cancer (SITC) released guidelines based on FDA approved immune checkpoint inhibitors (ICIs) for the treatment of urothelial cancer arising from the bladder and other areas of the urinary tract. The guidelines were based around therapies such as the programmed cell death protein 1 (PD-1) inhibitors Opdivo (nivolumab) and Keytruda (pembrolizumab) and the programmed cell death ligand 1 (PD-L1) inhibitors, Tecentriq (atezolizumab), Bavencio (avelumab) and Imfinzi (durvalumab).

The Society for Immunotherapy of Cancer (SITC) published an updated clinical practice guideline on July 15, 2021, titled “SITC clinical practice guideline on immunotherapy for the treatment of urothelial cancer.”

Experts updated and expanded evidence-based recommendations on immunotherapy treatment for urothelial cancer including diagnostic testing, treatment planning, immune-related adverse events (irAEs) and patient quality of life (QOL) to provide up-to-date information since the original 2017 guideline publication. The SITC Cancer Immunotherapy Guidelines Program consists of a multidisciplinary team of panel experts that develop evidence-based recommendations.

The guidelines discuss that the FDA has approved many immune checkpoint inhibitors (ICIs) for the treatment of urothelial cancer arising from the bladder and other areas of the urinary tract. The therapies included at the time of the guideline preparation include the programmed cell death protein 1 (PD-1) inhibitors Opdivo (nivolumab) and Keytruda (pembrolizumab) and the programmed cell death ligand 1 (PD-L1) inhibitors, Tecentriq (atezolizumab), Bavencio (avelumab) and Imfinzi (durvalumab).

The guidelines recommend the use of cystoscopy, urine cytology, and periodic upper tract imaging to detect recurrence for nonmuscle-invasive bladder cancer. Patients with PD-L1 negative tumors should receive carboplatin-based combination chemotherapy, and individuals with PD-L1 positive tumors can receive either immune checkpoint blockage or carboplatin-based chemotherapy.

The first-line treatment for metastatic urothelial cancer is platinum-based chemotherapy. Additionally, Tecentriq or Keytruda can be considered as first-line treatments for cisplatin-ineligible patients with PD-L1-positive tumors based on a companion assay. Keytruda, Bavencio, and Opdivo are also recommended for the treatment of patients with platinum-refractory metastatic urothelial cancer.

Another recommendation in the guidelines is that healthcare providers should discuss with patients the opportunity to participate in clinical trials at any stage of bladder cancer.ICIs are associated with various irAEs, most commonly in the gastrointestinal tract or skin. Generally, irAEs can be managed by temporarily withdrawing ICI treatment and/or with immunosuppressives (e.g. corticosteroids).The panel recommends consulting SITC’s guidelines for the management of irAEs in patient with bladder cancer.It is critical for healthcare providers to have conversations with their patients about all aspects of medical treatment, which include cost therapy options to improve QOL.