Stenzl - Figure 28
Which systemic therapy first?
FIG. 28: The next clinical question is, which systemic therapy should be given first in a patient with an advanced urothelial cancer? This question is a little future-oriented, because at present the only other systemic therapy available is programmed cell death ligand-1 (PD-L1) inhibitors, accepted for second-line therapy. These so-called "checkpoint inhibitors," which have recently been approved as second-line therapy following platinum-containing chemotherapy, have not been extensively studied yet in the neoadjuvant setting. However, since we know that we could use better therapy up-front, they will be investigated as first line, and then we will need to know which patients will need systemic therapy. It would also be an advantage if we could predict at a molecular level which patients would be responsive to adjuvant salvage therapy or might even be more responsive to second-line therapy, whether chemotherapy or the checkpoint inhibitors.
