Patient profiles as drivers of physician choice for first-line (1L) treatment (tx) in locally advanced or metastatic urothelial cancer (la/mUC): Perspectives from a US study.
Authors: Neil Milloy, Maria Walley, Amber Simpson, Cameron Forshaw, Valerie A. Morris, Mairead Kearney
Journal: Journal of Clinical Oncology (2025)

719 Background: As the number of tx options for patients with la/mUC increases, physicians aiming to optimize tx choice and sequencing must make complex decisions. Although recommended options provide clinical benefits, each has a distinct toxicity profile that limits its use in routine clinical care. This study assessed physician perspectives for 1L la/mUC tx selection based on hypothetical patient and disease characteristics. Methods: Data were drawn from the Adelphi Real World mUC Disease Specific Programme, a cross-sectional survey that captured data from medical oncologists and urologists responsible for treating people with la/mUC in the US, from Jan-July 2024. Physicians self-reported which 1L tx option they would be most likely to prescribe based on patient and disease characteristics provided. Tx options presented were: platinum-based chemotherapy followed by avelumab maintenance (PBC &amp; Ave), enfortumab vedotin plus pembrolizumab (EV &amp; P), cisplatin/gemcitabine plus nivolumab (cis/gem &amp; nivo), and other. Descriptive statistics were used for all analyses. Results: Of the 49 physicians who participated, 23 (47%) primarily worked in academic practices, 19 (39%) in community-based practices, and 7 (14%) in other care settings. At data collection, physicians were making tx decisions for a median of 24 patients with la/mUC (IQR, 10-44). Physicians most frequently reported that they would choose PBC &amp; Ave for patients with liver disease (53%) and EV &amp; P for patients with only lymph node involvement (55%). A breakdown of physician-reported 1L tx choices by patient/disease profile is presented in the Table. Conclusions: Despite the limited sample size, this real-world study provides contemporary insights into la/mUC tx choice among practicing US physicians in an evolving therapeutic landscape. We found heterogeneity in clinician-reported choices for 1L tx based on patient profiles, and inconsistency vs guideline recommendations. Multidisciplinary discussion and consensus are needed to support physicians in identifying patient profiles that may derive the greatest benefit from different 1L tx options while minimizing potential risks. Criteria that guide clinicians and inform policy decisions should evolve and gain broader acceptance as novel therapeutics are incorporated into routine care. Physician-reported 1L tx choice (N=49) Characteristic, n (%) PBC &amp; Ave EV &amp; P Cis/Gem &amp; Nivo Other Liver disease 26 (53) 16 (33) 7 (14) - Visceral disease 18 (37) 25 (51) 6 (12) - Liver metastases 17 (35) 22 (45) 10 (20) - Frail/elderly patients 9 (18) 24 (49) 8 (16) 8 (16) Pre-existing peripheral neuropathy 15 (31) 25 (51) 3 (6) 6 (12) Diabetes 24 (49) 19 (39) 5 (10) 1 (2) Only lymph node involvement 19 (39) 27 (55) 3 (6) - Low tumor burden 15 (31) 21 (43) 12 (24) 1 (2) High tumor burden 20 (41) 19 (39) 10 (20) -