Keytruda working, but Surgery Inevitable

Historically RC has better outcomes. More recent trials show EVP (padcev + pembro) can be medium term effective. Data is still maturing for long term. Pembro alone is not as common and therefore complicated. Case reports on Inspire/BCAN show occasional good outcomes with ICI (usually nivo instead of pembro but both are very similar) with subsequent RC. You did not specify if this is UC or prostate malignancy. Plus adding ctdna tracking can further inform status.

There are also case reports with atezo being effective long term but IMVIGOR led to discontinuation. Ave is another ICI sometimes indicated as salvage treatment after successful re-challenge with chemotherapy upon recurrence.

Same with balversa for egfr positive disease. Highly toxic unfortunately.

I'm sorry to hear about your dad's situation. We depend so much on our doctors it is challenging if they don't agree. I had my bladder removed (female age 55) but didn't have a choice in my situation (muscle invasive).

I will say that I noticed my oncologist take what the urologist (who is also my surgeon) recommended very seriously. My urologist is a little older and experienced than my oncologist but both are well respected. My oncologist deals with several different cancers and since my urologist had seen more cases I think it was wise to really consider his thoughts. No egos were involved on either side. They were a team that only had one goal in mind....my health and doing everything possible to get the cancer out and keep it from returning. The only thing they disagreed on was possible radiation at a site that showed a positive margin. The oncologist explained his concern about damaging my neobladder so we did not do it. The urologist thought it might be a good idea but the oncologist didn't want to risk damaging the new bladder. So far, it looks like the right decision. I get scans every three months just in case that could change. My surgery was nine months ago.

@wildvines, you may also be interested in this related (older) discussion:
- Bladder and prostate cancer, and neobladder reconstruction https://connect.mayoclinic.org/discussion/bladder-and-prostate-cancer/

Here are other related discussions: https://connect.mayoclinic.org/group/bladder-cancer/?search=bladder%20and%20porstate&index=discussions

@wildvines, I can understand being concerned about surgery. It sounds like you have unanswered questions for your father's cancer team. Sometimes chemo or immunotherapies (like Keytruda) are used to shrink tumors to improve the outcomes of surgery (get clear margins).

May I ask more about your concern? Are you worried that your father is well enough for surgery? Do you have concerns about bladder removal?

Thank you for the responses. We are mostly concerned about the lack of consensus between doctors. My dad is an active person and having his bladder removed is a big decision. My dad spoke with another patient who had between stage 2 and 3 bladder muscle invasive cancer who opted not to have his bladder removed. His urologist was able to see the cancer clearly with a scope, which informed his decision not to remove the bladder and only continue infusions. My dad's urologist implies that the scope does not provide a clear enough view of the cancer.

My impression is that the scope gives a pretty good view, depending on the location of the spot, as to if there is something suggesting a biopsy is needed or if something new has developed. The key is to get a sense if infusions (bcg?) are working and it therefore best to continue with the treatments. It's tough when you get different recommendations from different doctors, but that is what second opinions might say.

1. I need a dictionary of terms to understand what you are saying.
2. You sound very authoritative. Are you a doctor? It would help to inform. Thanks.

Please keep in mind that bladder removal doesn't mean a person has to give up being active. Much of it depends on a person's physical condition prior to the RC. It just may require some adjustments at times 😀. Only my two cents though. Others may feel differently. If you haven't sought another professional (oncologist/urologist) opinion out I would really encourage him to do so. Second opinions are very important. They help give you piece of mind.

Good luck to him. Let us know how he decides to move forward.

I am a patient. Have you tried to use Google and AI to educate yourself about your father's illness?

RC = radical cystectomy.
EVP = enfortumab vedotin (targets NECTIN4 and delivers a microscopic chemo payload) + pembrolizumab (PDL1 immune checkpoint inhibitor).

EVP-302 showed the combination works great:
https://www.nejm.org/doi/full/10.1056/NEJMoa2312117
So. nowadays, for locally advanced disease (stage 3 and above, N+ which means lymph node invasion) and metastatic disease, ICI alone is rare as it is typically the combined therapy.

PET, CT, MRI can provide additional visibility into the existence or not of the current tumor.

The whole point of case reports of successful complete response/remission/NED following ICI (Pembro, Atezo, Durva, Nivo, Ave) where RC was performed is curative intent through recurrence prevention.

There is also no between stages. You are either a stage or not.

The question is whether your father wants the best odds or wants to assume the risk of ICI failing at some point and having a local recurrence that could be refractory (non-responsive) to ICI. There are no guarantees either way so it is really a personal choice. His case is already unique due to pembro only and the suggestion of salvage RC.

A key question remains: is his cancer prostate cancer or bladder cancer? These are very different diseases with very different treatment regimes and outcomes.

@tms3: you are misinformed. Stage 3 means it is through the muscle layer or diverticulum (bladder pouch). That means BCG is not an option. That is only an option for non-muscle invasive disease. I am not sure why you would bring this up.

My husband is also taking the Keytruda. He's had his eighth infusion with no side effects. We've had your same experience. The oncologist is optimistic the immunotherapy will work. The surgical urologist is telling us that removal of the bladder is probably inevitable. But bladder preservation is our goal!

Interesting. Pembro only or combined with EV?