Metastatic Urothelial Carcinoma: Next-Line Treatment After Enfortumab Vedotin + Pembrolizumab Failed to Achieve Response
Clinical Scenario
This protocol applies to patients with metastatic or unresectable urothelial carcinoma who received first-line enfortumab vedotin combined with pembrolizumab and did not achieve the expected treatment response, requiring escalation to a subsequent line of therapy.
Patient Eligibility for This Line
- Metastatic or unresectable urothelial carcinoma
- ECOG performance status 0–2
- Glomerular filtration rate (eGFR) ≥ 30 mL/min
- Adequate organ functions and eligible for enfortumab vedotin
Previous Line — Failure Condition That Triggers This Protocol
First-line treatment was enfortumab vedotin in combination with pembrolizumab (continued until disease progression; pembrolizumab to a maximum of 35 cycles). Escalation to this line is indicated when that regimen did not achieve objective response or complete response.
Treatment Approach Partial preview
At this stage, treatment options centre on platinum-based combination chemotherapy regimens; further individualised alternatives exist depending on the patient's clinical and molecular profile. The complete options, sequencing, and decision criteria are in the structured protocol.
References
- The combination of EV + P represents the new standard of care for patients who are deemed fit for combination therapies.
- Use antibody-drug conjugate enfortumab vedotin (EV) in combination with checkpoint inhibitor (CPI) pembrolizumab.
- Major criteria include ECOG PS 0-2, GFR ≥ 30mL/min. and adequate organ functions based on eligibility for treatment with EV + P.
- Offer platinum-containing combination chemotherapy (cisplatin or carboplatin plus gemcitabine).
- If actionable fibroblast growth factor receptor (FGFR) alterations: offer erdafitinib.
- Offer single agent chemotherapy (docetaxel, paclitaxel, vinflunine).
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