Stage IV Bladder Cancer Then and Now: Before Immunotherapy

The statistics for Stage IV bladder cancer are not encouraging. But, as we are often told, individuals are not statistics. And I want to share with you why there is more reason than ever to be hopeful.

A very different landscape just five years ago

When my first husband, Ahmad, was diagnosed with metastatic bladder cancer in 2013, immunotherapies did not exist. The clinical trials for these drugs were just beginning. As result, the standard treatment for metastatic disease was chemotherapy, either the gemzar-cisplatin (or carboplatin) combination or the combination of drugs known as MVAC (or dose dense MVAC – ddMVAC). Both of these regimens are platinum-based chemotherapy. For many patients, they shrink tumors and allow for good quality of life. This was not, however, the case in Ahmad’s situation. His cancer actually progressed while on the gemzar-carboplatin regimen. Today, genomic sequencing to identify targeted therapies has become a norm as have immunotherapies. These were in their infancy just five years ago.

No change in metastatic bladder cancer therapies in nearly 30 years – until recently

The platinum-based chemo regimen was first approved for metastatic bladder cancer in 1978. Until 2016, no new drugs had been approved since then. This was shocking, and devastating, news to us. It was then that I realized that if you get cancer, you should hope to get one which has significant funding. Because funding results in treatment options. When I asked a primary care doctor in 2013, about why it was hard to find information online about metastatic bladder cancer she correctly (but cynically) said “you can’t build a career on bladder cancer.”

Increased research on immunotherapies

Thankfully, in 2018, we find that this is changing. Since the early immunotherapy clinical trials showed remarkable results for certain bladder cancer patients, there has been significant new interest in funding research. And this can be only good news for patients. The Food and Drug Administration (FDA) has approved five immunotherapy drugs (also known as checkpoint inhibitors) for locally advanced or metastatic bladder cancer that has progressed after platinum-based chemotherapy. Additionally, two (atezolizumab and pembrolizumab) are approved as first-line treatment options for those not eligible for cisplatin-based drugs. While these treatments are not working for everyone, they have greatly expanded the toolkit of options. Researchers are working hard to find the combinations that work for a given iteration of the disease or for a given patient.

Genomic sequencing also more widely available

The genomic sequencing of a patient’s tumor is another path to identifying a useful treatment. In Ahmad’s case, this was the only treatment that actually worked for him. This type of testing is more readily available than it was five years ago. In his case, the testing identified a drug normally given for kidney cancer or pancreatic cancer. He had a mutation that fewer than 10 percent of bladder cancer patients have. Genomic sequencing was cutting edge at the time and was not easy to obtain.

Significant strides for treating metastatic bladder cancer in just five years

The treatment landscape for metastatic bladder cancer has changed significantly in the last five years. The statistics can still seem grim but the expansion of treatment options to include genomic sequencing and immunotherapies can only continue to provide more good news for patients.

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