ADCs for Urothelial Carcinoma: Selection and AE Management


Advice regarding patient selection for sacituzumab govitecan and the management of treatment-related adverse events.

Petros Grivas, MD, PhD: Very quickly, Neeraj, do you have any take-home points for the audience regarding the optimal use of sacituzumab govitecan? The patients obviously have an indication after having progression on chemotherapy and checkpoint inhibitor, and they can get sacituzumab govitecan before or after enfortumab vedotin or before or after erdafitinib. Is there any patient profile based on medical comorbidities for which we would use sacituzumab govitecan as a third-line therapy?

Neeraj Agarwal, MD: After we discuss this, I’d also like to ask you another question about how to manage the adverse effects of enfortumab vedotin and sacituzumab govitecan. Because these are very new drugs, there’s a substantial amount of enthusiasm among my community oncology colleagues for using them. It would be nice to hear how you’re managing, especially neuropathy and skin rash, with EV [enfortumab vedotin] and how you’re managing neutropenia with sacituzumab govitecan.

But first, I tend to use enfortumab vedotin first and sacituzumab govitecan after based on the level of evidence. We have a phase 3 trial with EV [enfortumab vedotin] and a single-arm study with sacituzumab govitecan. That’s my take on the sequencing of these 2 antibody-drug conjugates [ADCs]. But there are certain instances in which I use sacituzumab govitecan before enfortumab vedotin or I use only sacituzumab govitecan. The first instance is with patients who have peripheral neuropathy that’s grade 2 or higher. I sometimes wonder if I should take the risk of using EV [enfortumab vedotin] or, because I have another effective ADC available, use that instead. I look for grade 2 peripheral neuropathy or higher.

Second, any time I see uncontrolled diabetes, with hemoglobin A1C [glycated hemoglobin] beyond 7.5%, I tend to use sacituzumab govitecan. Not always, but I tend to prefer SG [sacituzumab govitecan] over EV [enfortumab vedotin]. The third instance is when a patient is already dealing with substantial skin issues. If they already have skin toxicities from the previous treatment or there are skin lesions such as psoriasis, I always feel hesitant about using any other drug which may be dermatologically toxic. In those circumstances, I would use SG [sacituzumab govitecan] first and then EV [enfortumab vedotin] after because we don’t have other options available. That would be my preference for a sacituzumab govitecan to be used first, before enfortumab vedotin.

Transcript edited for clarity.

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