Navigating Neuropathy in Urothelial Cancer Treatment
Expert perspective on the impact of neuropathy on treatment choices in urothelial cancer, providing insight into identifying and managing peripheral neuropathy and exploring suitable treatment options.
Transcript:
Arlene O. Siefker-Radtke, MD: So let’s get back to our patient who’s been very patiently waiting in clinic while we’ve been having this discussion regarding what treatment options are available for this patient. Again, type 2 diabetes. We want to ask him, do you have peripheral neuropathy? And for someone who has poorly controlled diabetes as well, I suspect he does indeed have that neuropathy. And if it’s agreed to, then I would definitely choose one of the alternatives to enfortumab, such as erdafitinib if an FGF alteration is present or treatment with sacituzumab govitecan. So asking the patient, do they have neuropathy? How is it impacting their daily life?
Grade 2 neuropathy is a bit subjective, but 1 important question that I find helps identify it: I ask the patient, when they shower, do they have to touch the shower wall? Because the moment they close their eyes they lose that visual spatial acuity, telling them where the ground is. So when they close their eyes, that’s when they feel that they’re losing their balance. And if they’re touching the wall of the shower, for me, that’s been a strong signal that this is likely a grade 2 peripheral neuropathy impacting their ability to feel the ground and placing them at an increased risk of falls. I often instruct them, maybe it’s time to get some shower handles up in the shower and get them placed by a professional so you can hold on to it and avoid any of those devastating falls that can have a significant impact on the outcomes of our patients.
So as we walk back into the clinic, we ask this patient, do you have neuropathy? And unfortunately, he does. He has a grade 1 neuropathy that actually became grade 2 as a result of the prior cisplatin. He does have to touch the wall of the shower when he showers to feel where he is, otherwise, he feels like he is about to fall over. There’s no FGFR3 mutation present on this patient because you were smart enough. You got that test early, so you know that that is not an option for him. So in this case, I would discuss treatment with sacituzumab govitecan, which again, on the basis of a phase 2 clinical trial where it was granted FDA accelerated approval, has an objective response rate of around 25% and had a median survival that appeared quite promising as well. The patient will be coming in on day 1 and day 8 of a 3-week cycle, and I personally do prefer the use of prophylactic growth factor support given the high rates of neutropenia that I have personally observed in my clinic patients.
Transcript is AI-generated and edited for clarity and readability.
Case: A 73-Year-Old Man with Metastatic Urothelial Carcinoma
Initial Clinical Presentation:
- A 73-year-old man presented to you from their local urologist with dizziness and hematuria
- PMH: hypertension and diabetes (uncontrolled)
- SH: former smoker; consumes alcohol 2-3 times per week
- Chest x-ray and CT revealed a 3.7-cm mass on the right lateral wall of the bladder and liver metastases
- Cystoscopic biopsy/pathology confirmed stage IV urothelial carcinoma
- ECOG PS 1
- CrCl 65 mL/min
- The patient received gemcitabine + cisplatin (6 cycles)
- Partial response at completion of chemotherapy
- No maintenance therapy given, although discussed with patient
Current Clinical Presentation:
- 7 months later, disease progression was discovered on routine follow up imaging
Treatment:
- The patient received pembrolizumab and a partial response was achieved at 6 cycles
- Molecular testing showed no FGFR2 mutation or fusion
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