Metastatic or Unresectable Urothelial Carcinoma with Reduced Renal Function (eGFR 30–60 mL/min): Treatment When Cisplatin Is Not an Option and Enfortumab Vedotin Is Unavailable
Approximately half of patients with bladder cancer are not eligible for cisplatin-based chemotherapy. This protocol addresses a specific subset: those with metastatic or unresectable urothelial carcinoma who cannot receive cisplatin, and for whom enfortumab vedotin is also contraindicated or unavailable — a population requiring a distinct first-line strategy.
The patient has metastatic or unresectable urothelial carcinoma and is ineligible for cisplatin-based chemotherapy due to reduced renal function (eGFR 30–60 mL/min) or an ECOG performance status of 2. Carboplatin-based chemotherapy is feasible. Enfortumab vedotin is contraindicated or not available, directing care to an alternative pathway. Platinum-containing combination chemotherapy followed by maintenance immunotherapy is considered for patients achieving at least stable disease.
Where feasible, biomarker-directed systemic options — including an antibody-drug conjugate for patients with specific receptor overexpression, and a targeted agent for those with actionable molecular alterations — may form part of the individualised plan; the complete eligibility criteria, sequencing, and full regimen are set out in the protocol.
If contraindications for EV or EV not available: Offer platinum-containing combination chemotherapy (cisplatin or carboplatin plus gemcitabine) followed by maintenance treatment with CPI avelumab in patients with at least stable disease on chemotherapy.
Approximately 50% of patients with BC are not eligible for cisplatin-based chemotherapy.
Offer antibody-drug conjugate Trastuzumab deruxtecan in case of human epidermal growth factor receptor (HER) 2 over expression (IHC 3+) and consider in case of HER2 (IHC 2+).
If actionable FGFR alterations: offer erdafitinib.
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