Using checkpoint inhibitors in renal transplant recipients requires extreme caution due to a significant risk of graft rejection, potentially leading to dialysis. This decision is a major trade-off and must involve a case-by-case discussion with the patient and a nephrologist.
When immunotherapy is not an option for metastatic bladder cancer, enfortumab vedotin (EV) monotherapy is an attractive choice over traditional cisplatin chemotherapy, especially if a rapid tumor response is critical or if the patient has baseline neuropathy or renal issues that make chemotherapy tolerance uncertain.
An 80-year-old patient and his wife wisely questioned the value of a circulating tumor DNA (ctDNA) test by asking, "if you're not going to act on it, why would we send this?" This serves as a powerful reminder for clinicians to only order tests that will directly influence treatment decisions, respecting patient-centered, high-value care.
For elderly or frail patients with metastatic bladder cancer, treatment choice hinges on goals. Enfortumab vedotin (EV) monotherapy is preferred for a rapid response in symptomatic or bulky disease. In contrast, pembrolizumab monotherapy is better for a lower-intensity approach in patients with low-volume disease where durable benefit and quality of life are prioritized.
Despite its use in other cancers, PD-L1 expression level is not used to guide immunotherapy decisions in the metastatic bladder cancer setting. Experts describe the correlation between PD-L1 status and patient outcomes as a "mess," making it clinically irrelevant for treatment selection in this disease.
While trials like IMvigor011 show ctDNA can guide adjuvant immunotherapy after surgery, this data may not apply to the new standard of care. With neoadjuvant EV/pembrolizumab becoming prevalent, the prognostic and predictive value of post-operative ctDNA is now unknown, requiring new prospective studies.