Further Reading

Treatment of Metastatic MIBC

Metastatic BC is associated with an overall poor prognosis. It might be approached using the Bajorin classification based on performance status (PS), location of the metastases and haemoglobin level. The median survival is around 36 months (Karnofsky PS > 80, no visceral metastases, normal haemoglobin level) compared with 12 months if PS < 80, visceral metastases and anaemia are present.

The standard regimen is cisplatin-based polychemotherapy (either MVAC, DD MVAC or GC). The response rate is around 50%, the complete response rate around 20%, and the overall median survival around 14 months. The main prerequisite is an adequate renal function, either estimated using the MDR formula, or a real measured renal clearance.

There are limited data on senior adults as they are under-represented in clinical trials. Furthermore, they often have a decreased bone marrow reserve. At least 50% are unfit for cisplatin either due to poor renal function (creatinine clearance < 60 ml/min) and/or an ECOG PS < 2. In cases where one of these two criteria is met, the options are limited to carboplatin-based combination regimens (such as carboplatin –gemcitabine). When both criteria are met, based on the very poor outcome, a detailed discussion is mandatory as best supportive care/palliative care might often represent the best treatment option.

Relapse after first-line treatment is associated with a median survival between 5 to 12 months, depending on several risk factors. In theory if the relapse is more than 6-12 months after the first regimen, another platinum-based regimen is standard of care, if feasible. This will be the exception in senior adults. Provided the patient has a PS 0-1, a vinflunine-based regimen might be discussed. Otherwise best supportive/palliative care will be the standard.

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