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To summarize, this is a cisplatin-ineligible patients, who 'may' also be platinum-ineligible. The options off-trial are as follows in the following order in my mind:
1. Carboplatin+Gemcitabine x 4-6 cycles -->avelumab maintenance (if stable or responding) per JAVELIN Bladder-100 trial (although this patient is 'felt' to be platinum, i.e. chemo-ineligible, there is no clear definition of this group. Transient predictable myelosuppression from chemotherapy is in many ways more feasible to mitigate and manage than a severe immune adverse event.
2. Pembrolizumab (or atezolizumab) as firstline therapy is reasonable under the umbrella of platinum-ineligibility. However, in my practice, I have used tumor PD-L1 IHC status to guide me if I am contemplating firstline pemro or atezo- i.e. if PD-L1 expression high, I am comfortable offering firstline pembro, and if PD-L1 is low, I prefer the JAVELIN Bladder-100 approach in #1 above (which demonstrated benefit regardless of PD-L1 status)..
Pending Moderator approval.
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