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Multidisciplinary Care: UBC
Working With a Multidisciplinary Care Team: Considerations for Immunotherapy in Bladder Cancer

Released: May 22, 2018

Expiration: May 21, 2019

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A multidisciplinary approach to the treatment of patients with metastatic and locally advanced urothelial carcinoma is crucial to optimizing patient outcomes, including OS. In other solid tumors, such as prostate cancer, it has been noted that a multidisciplinary approach leads to better survival. This is as critical—if not more critical—in bladder cancer where studies have demonstrated that the earlier use of chemotherapy, particularly in the neoadjuvant setting, improves survival. Despite this, the uptake of systemic neoadjuvant therapy in this setting has been underwhelming.

In general, urologists are the “gate keepers” for bladder cancer: They are typically the people who make the primary diagnosis and therefore make the initial treatment decisions. Multidisciplinary care teams, including the diagnosing urologist along with radiation oncologists, medical oncologists, surgeons, and nurses, can work together to improve patient outcomes. A patient with locally advanced bladder cancer should be offered all options for treatment. For example, if a patient is platinum eligible, he or she should first be considered for initial neoadjuvant chemotherapy prior to surgery. If the patient does not achieve a pathologic CR, the multidisciplinary team should consider referral to ongoing clinical trials, such as those evaluating adjuvant therapy with immune checkpoint inhibitors.

On the other hand, it is also important for urologists to recognize that there are now other options aside from traditional first-line chemotherapy for their patients with metastatic disease, particularly those who may not have been able to receive treatment in the past. Historically, patients who were not eligible for platinum-based chemotherapy would receive palliative chemotherapy or referral to hospice. However, now that immune checkpoint inhibitor therapy with pembrolizumab or atezolizumab is FDA approved for patients who are ineligible for platinum-based chemotherapy, having a discussion with a multidisciplinary care team may help identify patients who could benefit from first-line immunotherapy.

Of note, once patients transition from their urologists to oncologists to start immunotherapy, patients tend to stay with their oncologists rather than return to their urologists or primary care physicians for additional bladder cancer care. However, if patients do return to their primary care physicians or urologists for any reason, it is important to have an open line of communication to discuss management issues related to patients’ bladder cancer therapy. If a clinician inside or outside the multidisciplinary care team sees a patient who is receiving immune checkpoint inhibitors, it is important for the clinician and the patient to understand the differences in presentation and management of immune-related adverse events, such as colitis, compared with adverse events experienced while receiving chemotherapy. It is critical for clinicians to manage immune related adverse events promptly and appropriately. For example, if a patient is seen by their primary care provider or in an ER for symptoms of immune-mediated colitis, but they are treated for infectious colitis, this could be detrimental to the patient’s health and could allow symptoms to escalate. It is important that the entire care team, and the patient, is educated on identifying immune related AEs, who to contact if these symptoms do occur, and how to manage these adverse events.

One way for multidisciplinary teams to understand various treatment decisions is to use decision aids or interactive online tools that help guide management decisions for their patients. This online treatment decision tool for bladder cancer, developed by me and my colleagues—Matthew Galsky, MD; Matthew I. Milowsky, MD; Elizabeth R. Plimack, MD, MS; and Jonathan E. Rosenberg, MD—can provide some insight on what treatment we would select for your type of patient with bladder cancer. In addition, this interactive algorithm tool allows clinicians to enter the specifics of a patient’s immune-related adverse events to see the recommended management approach based on available data and expert recommendations.

What challenges have you had in implementing multidisciplinary treatment of patients with bladder cancer? Share your thoughts in the comment box below.
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What is the greatest challenge you face regarding neoadjuvant therapy for eligible patients with resectable bladder cancer?
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