First-Line Treatment Patterns Among Patients With Locally Advanced or Metastatic Urothelial Cancer (la/mUC): A Systematic Literature Review

OBJECTIVES: The outcomes of patients with la/mUC are poor; however, systemic treatments (STs) including chemotherapy sequenced by maintenance immunotherapy (IO) are available to extend survival. First-line (1L) treatment patterns and reasons for no receipt of ST (NST) are not well known. We aimed to characterize 1L treatment patterns, NST, attrition rates across line of therapy, and factors influencing treatment selection for patients with la/mUC.

METHODS: We conducted a systematic literature review of real-world studies reporting NST and/or attrition rates in patients with la/mUC published from 2017 to 2022 (including data from 2015 or later). In the absence of statistics describing associations of patient characteristics with NST, we performed Fisher’s exact tests.

RESULTS: Among 2,439 publications screened, 66 reported treatment patterns, 1L NST rates, and/or attrition rates. 29 studies reported NST rates: 8 European-based studies reported NST rates of 40%-74%, 12 US-based studies reported 14%-60%, and 9 studies from the rest of the world, including Japan, Canada, and Russia, reported 9%-63%. Of the 8 studies reporting survival, the median OS was 2.0-6.9 months with NST and 9.2-34.5 months with ST. Few studies reported factors associated with NST or attrition; associated characteristics reported included older age and female sex in addition to poor performance status, poor renal function, and distant metastases. Rates of receipt of 2L ST were lower among cisplatin-ineligible vs -eligible patients (37% vs 49%) and among those who received 1L IO vs 1L chemotherapy (31% vs 47%).

CONCLUSIONS: Our analysis revealed that a substantial proportion of patients with la/mUC were undertreated or not treated according to guidelines, which recommend, for eligible patients, 1L treatment with platinum-based chemotherapy followed by avelumab maintenance. Given the availability of effective treatments, more research is needed to better understand real-world treatment selection and optimal treatment sequencing.