Patients with non-muscle invasive bladder cancer, even after years of clear surveillance cystoscopies, can develop widespread metastatic disease de novo. This rare but real phenomenon questions the adequacy of current imaging surveillance guidelines for patients considered to have low-risk disease, suggesting a potential role for ctDNA.
To prevent irreversible toxicities like neuropathy from enfortumab vedotin, clinicians should proactively set expectations. Emphasize that dose adjustments are normal and part of a long-term strategy. Framing it as a "marathon, not a sprint" encourages patients to report side effects early, rather than hiding them for fear of stopping treatment.
In bladder cancer patients on combination therapies like EV-PEMBRO, diarrhea should not be automatically attributed to treatment-related colitis. Clinicians must maintain a broad differential diagnosis, including common mimics like C. diff infection (due to frequent antibiotic use) and less common ones like pancreatitis, before escalating immunosuppression.
A history of autoimmune disease, even one requiring treatment like methotrexate for rheumatoid arthritis, should not be an absolute contraindication for immune checkpoint inhibitors. In collaboration with specialists, patients with well-controlled psoriasis, IBD, or even multiple sclerosis can often safely receive immunotherapy and achieve prolonged responses.
The management of treatment-induced pneumonitis differs significantly between drug classes. While clinicians may treat through low-grade pneumonitis from immune checkpoint inhibitors, the safest approach for antibody-drug conjugates (ADCs) like TDXD is to stop the drug immediately upon any radiographic evidence, even if the patient is asymptomatic.