Treatment of Stage IV Bladder Cancer with Borderline ECOG Performance Status

Initial Critical Evaluation

• The European Society for Medical Oncology recommends determining the exact ECOG performance status, as ECOG 2 patients have limited benefit from platinum-based chemotherapy, and early palliative care with palliative radiotherapy should be considered for symptom control, such as pain and bleeding 1
• The National Comprehensive Cancer Network suggests assessing renal function, including serum creatinine and creatinine clearance, to determine eligibility for cisplatin 2
• The presence of visceral metastases, combined with ECOG ≥2, strongly predicts poor outcomes with chemotherapy 2

Treatment Algorithm by Performance Status

ECOG 0-1 (Good Performance Status)

• The American Society of Clinical Oncology recommends enfortumab vedotin + pembrolizumab as the preferred first-line treatment, with a median overall survival of 31.5 months versus 16.1 months with chemotherapy (HR 0.47) 3

ECOG 2 (Borderline Performance Status)

• The European Society for Medical Oncology notes that patients with ECOG 2 and compromised renal function have limited benefit from chemotherapy, and early palliative care with palliative radiotherapy should be considered for symptom control 1
• The National Comprehensive Cancer Network suggests considering carboplatin-based regimens or single-agent therapy for patients with preserved renal function 1

Palliative Radiotherapy: Specific Protocols

• The European Society for Medical Oncology recommends palliative radiotherapy protocols, including 8 Gy in 1 fraction, 21 Gy in 3 fractions, 20 Gy in 5 fractions, or 36 Gy in 6 fractions, for symptom control, such as pain, bleeding, and obstruction 4

Considerations for Locally Advanced Disease (T4b N1)

• The European Society for Medical Oncology suggests that selected patients with locally advanced disease may be candidates for cystectomy + lymphadenectomy or definitive radiotherapy after systemic therapy, provided they have responded to initial systemic chemotherapy and have improved performance status 4, 1

Common Pitfalls to Avoid

• The National Comprehensive Cancer Network advises against substituting cisplatin with carboplatin in the perioperative setting, as carboplatin is not a suitable substitute 2
• The European Society for Medical Oncology recommends avoiding aggressive chemotherapy in patients with ECOG ≥2 and visceral metastases, as they have poor outcomes 2
• The American Academy of Hospice and Palliative Medicine suggests not delaying palliative care, which should be initiated early in the course of stage IV disease 5, 1