Chair, Petros Grivas, MD, PhD, Shilpa Gupta, MD, and Srikala Sridhar, MD, MSc, FRCPC, prepared useful Practice Aids pertaining to bladder cancer for this CME/MOC activity titled “Achieving State-of-the-Art Care in Bladder Cancer in an Era of Innovative Therapeutic Solutions.” For the full presentation, downloadable Practice Aids, and complete CME/MOC information, and to apply for credit, please visit us at https://bit.ly/3sVESzQ. CME/MOC credit will be available until February 17, 2023.

1. Patient Education:
Understanding Bladder Cancer Treatment Options
Full abbreviations, accreditation, and disclosure information available at PeerView.com/JKS40
Receiving a diagnosis of bladder cancer can be overwhelming
for patients and their caregivers. Please use the following one-page,
printable resource to help your patients and their caregivers understand
bladder cancer treatment options and where they can turn for more support.
Printable Resource

2. If you experience any side effects, immediately contact your doctor!
Bladder cancer treatment can result in a number of side effects depending on the
type of treatment regimen chosen. Talk to your doctor about possible risks and the
impact treatment may have on your quality of life.
Questions to Ask Your Doctor
• What kind of bladder cancer do I have?
• What is the stage of the disease? Has the cancer spread?
• What is the grade of the tumor?
• What are my treatment choices? Which do you recommend for me? Why?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment?
• What is the treatment likely to cost? Is this treatment covered by my
insurance plan?
• How will treatment affect my normal activities?
Bladder
lumen
Lamina
propria
Inner
muscle
Outer
muscle
Tis Ta
T1
T2a T2b T3
T4
Tumor invades
adjacent tissues
and organs
Tumor invades
perivesical tissue
Tumor invades
deep muscle
Tumor invades
superficial muscle
Tumor invades
subepithelial
connective tissue
Non-invasive
papillary
carcinoma
Carcinoma
in situ
Urothelium
Tis: Carcinoma in situ (flat tumor), sometimes called Cis
Ta: Non-invasive papillary carcinoma
T1: The tumor is in the first layer of the bladder lining, but not the
surrounding muscle
T2: The tumor has grown into the muscle
T3: The tumor has spread to the fatty layer around the bladder muscle
T4: The tumor has spread to organs outside the bladder or to the wall
of the abdomen
What Are the Different Stages of Bladder Cancer?
Spotlight on Clinical Trials
Your cancer care team may offer you the option of enrolling in a clinical trial.
These studies provide important information on whether a treatment is safe
and effective and give you access to new strategies that could be better
than the options currently used.
Clinical trial enrollment is voluntary. Each trial has specific enrollment criteria
(eg, age, type of cancer, stage, prior treatments). Talk to your patient care team
about whether clinical trial enrollment is right for you.
What Are Some of the Different Treatment Options For Bladder Cancer?
Your team will let you know what to expect from each treatment, including how the
medicine is given, which side effects are common, and how the medication may affect
your lifestyle, so you and your team can choose a treatment plan that best fits your needs.
➦ Transurethral resection of a bladder tumor (TURBT) is an incision-less procedure
to remove a tumor
➦ Intravesical approaches allow for medications to be placed directly into the bladder
➦ Radical cystectomy (bladder removal surgery) may be required, and certain medications
may be given before (neoadjuvant) or after (adjuvant) the surgery
➦ Chemotherapy may be selected depending on a patient’s individual needs and overall health
➦ Immunotherapy, an agent that uses a person’s own immune system to fight cancer, may
also be an option
➦ Newer treatments, including some that target genetic alterations (FGFR inhibitors, PARP
inhibitors) and other specific cancer proteins (antibody–drug conjugates), are also available
➦ Finally, combining therapeutic options may also be a possibility in certain cases
Online and in-person advocacy foundations for patients and their caregivers
provide a variety of services, including support groups, information on treatments,
genetic testing and clinical trials, and educational workshops.
Visit these links to learn more about the resources each organization offers.
Where Can You Get More Support?
American Cancer Society:
cancer.org/treatment/
support-programs-and-services
BCAN (Bladder Cancer
AdvocacyNetwork):
bcan.org/find-support
World Bladder Cancer
Patient Coalition:
worldbladdercancer.org
Understanding Bladder Cancer: A Quick Reference for Patients
If you or someone you love has been diagnosed with bladder cancer or urothelial carcinoma, you may have a lot of questions
about treatment options and where you can turn for help.
What Side Effects Are Associated With Bladder Cancer Treatment?

3. Guide to Managing Adverse Events
Associated With Therapies
for Urothelial Carcinoma
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/JKS40
• In general, checkpoint inhibitor therapy should be continued with close monitoring,
with the exception of some neurologic, hematologic, and cardiac toxicities
Minimal or no symptoms; diagnostic changes only
Grade 1
• Hold checkpoint inhibitor therapy for most grade 2 toxicities
• Consider resuming immunotherapy when symptoms and/or laboratory values
revert to grade 1 or lower
• Corticosteroids (initial dose of 0.5-1 mg/kg/d of prednisone or equivalent) may
be administered
Grade 3 toxicities
• Hold checkpoint inhibitor therapy
• Initiate high-dose corticosteroids (prednisone 1-2 mg/kg/d or methylprednisolone
IV 1-2 mg/kg/d)
• If symptoms do not improve with 48-72 hours of high-dose corticosteroids,
infliximab may be offered for some toxicities
• Taper corticosteroids over the course of at least 4-6 weeks
• When symptoms and/or laboratory values revert to grade 1 or lower, rechallenging
with immunotherapy may be offered; however, caution is advised, especially in
those patients with early-onset irAEs; dose adjustments are not recommended
Grade 4 toxicities
• In general, permanent discontinuation of checkpoint inhibitor therapy is warranted,
with the exception of endocrinopathies that have been controlled by hormone
replacement
Grade 2
Mild to moderate symptoms
Severe or life-threatening symptoms
Grades 3/4
Immune checkpoint inhibitors are associated with important clinical
benefits, but general immunologic enhancement can also lead to a
unique spectrum of immune-related adverse events (irAEs)1,2
irAEs are often diagnosed by
exclusion; other causes should
be ruled out (including AEs of
other therapies used), but
immunotherapy-related toxicity
should always be included
in the differential
There should be a high level of
suspicion that new symptoms
are treatment related; early
recognition, evaluation, and
treatment of irAEs plus patient
education are essential for
best outcomes
Depending on the severity
of irAEs, management may
require corticosteroid or
other immunosuppressive
treatment as well as
interruption or
discontinuation of therapy
If appropriate,
immunosuppressive
treatment is used; patients
generally recover from irAEs
How should irAEs be diagnosed?
What are the general recommendations
for irAE management?
What is the spectrum of potential irAEs?
Pancreatitis,
autoimmune diabetes
Colitis
Enteritis
Encephalitis, aseptic meningitis
Thyroiditis, hypothyroidism,
hyperthyroidism
Dry mouth, mucositis
Hypophysitis
Uveitis
Pneumonitis
Thrombocytopenia,
anemia
Hepatitis
Adrenal insufficiency
Nephritis
Vasculitis
Arthralgia
Neuropathy
Rash, vitiligo
Myocarditis
Any organ system can be affected; commonly occurring irAEs are pulmonary
(pneumonitis), dermatologic (rash, pruritus, blisters, ulcers, vitiligo),
gastrointestinal (diarrhea, enterocolitis, transaminitis, hepatitis, pancreatitis),
and endocrine (thyroiditis, hypophysitis, adrenal insufficiency)
Why do
irAEs occur?
“Taking the brakes off”
of the immune system can
help the body fight cancer,
but it can also lead to
toxicity from a
“supercharged”
immune system.

4. Guide to Managing Adverse Events
Associated With Therapies
for Urothelial Carcinoma
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/JKS40
Safety Management for
FGFR Inhibitor Therapy8,9
Erdafitinib
 Mucositis, other oral toxicities
Oral
 Monitor for toxicities
 Refer to dermatology and
podiatry as needed
Skin and Nail
 Dietary phosphate may require
restriction
 Individualized dietary plan
from nutrition professional
 Consider adding a
non–calcium-containing
phosphate binder (eg,
sevelamer carbonate)
Dietary
FGF FGF
FGF
FGF
FGFR
HSPG
FGF FGF
FGFRL1
SEF
SPRY
FRS2
PLC-y
DAG STAT
GAB1
SOS
GRB2
RAS RAF
MEK
ERK MKP3
MKP1
AKT
PKC
PI3K
Nucleus
Transcription of
target genes
Cytoplasm
Extracellular
PIP2
P
P
P
P
P
P
P
P
P
P
P
P
IP3
Plasma membrane
Proliferation
and survival
Resistance to
anticancer agents
Neoangiogenesis
FGFR alterations:
Amplification (receptor
overexpression) or
mutation/translocation
(ligand-independent
signaling)
FGF ligand:
Amplification
(autocrine) or
ECM/stromal-
cell release
(paracrine)
FGFR in UC3-7
FGFR Signaling Pathway
FGFR is altered in 15% to 20% of advanced UC.
Mutated FGFR3 is present in 37% of upper-tract UC.
FGFRs are a family of receptor tyrosine kinases that are upregulated in multiple different cancers
and are involved in tumor cell differentiation and proliferation, tumor angiogenesis, and tumor cell
survival; alterations in the FGFR gene, such as mutations and translocations, have been implicated
in the pathogenesis of UC
 Eye exams
 Withhold for any occurrence of
CSR or RPED
 Discontinue permanently if CSR/
RPED symptoms do not resolve
in 4 wk or if they escalate to grade 4
Ocular

5. Guide to Managing Adverse Events
Associated With Therapies
for Urothelial Carcinoma
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/JKS40
Sacituzumab Govitecan
Antibody–Drug Conjugates10
Antibody–drug conjugates (ADCs) are molecules composed of an antibody chosen based on its ability to target a
tumor-specific protein linked to a cytotoxic payload or drug, enabling it to deliver a cytotoxic agent directly to the
targeted cells while minimizing toxicity to healthy cells
Enfortumab Vedotin
Peripheral Neuropathy
 Generally resolves/remains at grade 1
Hyperglycemia
 Monitor blood glucose (patients with/at risk for
diabetes or hyperglycemia)
Maculopapular Diffuse Rash
 Topical steroids
 Antihistamines
 Dose reductions/delays
 Systemic corticosteroids (special cases)
Diarrhea
 Educate patients
 Hydration with electrolytes
 Anti-diarrheal medications
 Best supportive care
Safety Management for Antibody–Drug
Conjugate Therapy11-13
1Binds to
antigen
2Complex is internalized
and traffics to lysosome
3Payload is released
and causes cell death
Neutropenia
 Consider growth factor support
 Dose reduction or hold
Sacituzumab Govitecan
Enfortumab Vedotin
Target: Nectin-4, a type 1 transmembrane cell
adhesion molecule overexpressed in epithelial cancers
Linker: Protease cleavable
Payload: MMAE
Target: Trop-2, an epithelial cell-surface glycoprotein
highly expressed in muscle-invasive disease
Linker: Hydrolysable
Payload: SN-38, the active metabolite of irinotecan
1. Postow MA et al. N Engl J Med. 2018;378:158-168. 2. Brahmer JR et al. J Clin Oncol. 2018;36:1714-1768. 3. https://tcga-data.nci.nih.gov/docs/publications/tcga.
4. Knowles MA et al. Nat Rev Cancer. 2015;15:25-41. 5. Rodriguez-Vida A et al. J Hematol Oncol. 2015;8:119. 6. Li Q et al. Curr Urol Rep. 2016;17:12. 7. Touat M et al. Clin Cancer Res. 2015;21:2684-2694.
8. Loriot Y et al. N Engl J Med. 2019;381:338-348. 9. Balversa (erdafitinib) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/212018s001lbl.pdf. 10. Parslow AC et al.
Biomedicines. 2016;4:14. 11. Rosenberg JE et al. J Clin Oncol. 2019;37:2592-2600. 12. Loriot Y et al. Ann Oncol. 2020;31(suppl 4)s1142-s1215. 13. Petrylak DP et al. J Clin Oncol. 2020;38(suppl): Abstract 5027.

6. DRUG/TARGET INDICATION DOSING
Approved for the treatment of adult pts with locally advanced UC or mUC who have previously
received a PD-1 or PD-L1 inhibitor and platinum-containing chemotherapy in the
neoadjuvant/adjuvant, locally advanced, or metastatic setting
Approved for the treatment of pts with locally advanced UC or mUC who are ineligible for
cisplatin-containing chemotherapy and have received ≥1 prior line of therapy
Antibody–Drug Conjugates
Enfortumab vedotin6
Nectin-4
1.25 mg/kg (≤125 mg)
as IV infusion over
30 min on d 1, 8, and 15 of
a 28-d cycle until disease
progression or toxicity
Approved for the treatment of pts with locally advanced or metastatic disease
who are platinum ineligible
Approved for the treatment of pretreated pts with locally advanced UC or mUC who
progressed on prior platinum-based tx or relapsed within 1 y of perioperative
platinum-containing chemotherapy tx
Approved for the treatment of pts with BCG-unresponsive, high-risk NMIBC with CIS with
or without papillary tumors who are ineligible for or have elected not to undergo cystectomy
Pembrolizumab4
PD-1
200 mg every 3 wk
or 400 mg every 6 wk
240 mg every 2 wk
or 480 mg every 4 wk
Approved for the treatment of pretreated pts with locally advanced UC or mUC who
progressed on prior platinum-based tx or relapsed within 1 y of perioperative cisplatin tx
Approved for the adjuvant treatment of pts with UC who are at high risk of
recurrence after undergoing radical resection of UC
Nivolumab3
PD-1
Immune Checkpoint Inhibitors
Atezolizumab1
PD-L1
840 mg every 2 wk,
1,200 mg every 3 wk,
or 1,680 mg every 4 wk
Approved for the treatment of newly diagnosed pts with cisplatin-ineligible locally
advanced UC or mUC and PD-L1+ tumors (tumor-infiltrating ICs covering ≥5%
of the tumor area) or who are platinum ineligible
Companion diagnostic: Ventana PD-L1 (SP142) Assay
Approved for the treatment of pretreated pts with locally advanced UC or mUC who
progressed on prior platinum-based tx or relapsed within 1 y of perioperative
platinum-containing chemotherapy tx
Approved for maintenance treatment of pts with locally advanced UC
or mUC who has not progressed with first-line platinum-containing chemotherapy
Avelumab2
PD-L1
800 mg every 2 wk
Trop-2
10 mg/kg on d 1 and 8,
every 21 d until disease
progression or toxicity
Approved for the treatment of pts with locally advanced
UC or mUC who have had prior treatment with a PD-1 or PD-L1 inhibitor
and a platinum-containing chemotherapy regimen
Sacituzumab govitecan7
Approved for the treatment of pretreated pts with locally advanced UC or mUC who have
FGFR2 or FGFR3 genetic alterations and who progressed on prior platinum-based tx
or relapsed within 1 y of perioperative platinum-containing chemotherapy tx
Companion diagnostic: therascreen®
FGFR RGQ RT-PCR Kit
Erdafitinib5
FGFR
8 mg daily with
an increase
to 9 mg daily based on
PO4
levels and tolerability
at 14 to 21 d
FGFR Inhibitors
Therapeutic Targets, Indications, and Dosing Information
A Snapshot of Approved Therapies and
Ongoing Investigations in Urothelial Carcinoma
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/JKS40

7. Selected Ongoing Clinical Trials of Innovative Treatment Options in Urothelial Carcinoma8
First-Line Metastatic Second-Line Metastatic
Bladder Preservation
Adjuvant MIBC
NMIBC
Neoadjuvant
CheckMate -901 (NCT03036098) phase 3:
nivolumab + ipilimumab vs nivolumab + chemo vs chemo
NILE (NCT03682068) phase 3:
durvalumab + chemo ± tremelimumab vs chemo
BAYOU (NCT03459846): durvalumab ± olaparib
in platinum-ineligible patients
AMBASSADOR (NCT03244384) phase 3:
pembrolizumab vs observation
IMvigor010 (NCT02450331) phase 3:
PROOF 302 (NCT04197986) phase 3:
infigratinib vs placebo
PEGASUS (NCT04294277) phase 2: pemigatinib
atezolizumab vs observation
ENERGIZE (NCT03661320) phase 3:
nivolumab + chemo or nivolumab +
linrodostat (IDO1 inhibitor) + chemo
→ immuno-oncology therapy after radical
cystectomy vs chemo
KEYNOTE-866 (NCT03924856) phase 3:
perioperative pembrolizumab +
neoadjuvant chemo vs perioperative placebo +
neoadjuvant chemo
VOLGA (NCT04960709) phase 3:
durvalumab + enfortumab vedotin ± tremelimumab
vs cystectomy
KEYNOTE-B15 (NCT04700124) phase 3:
pembrolizumab + enfortumab vedotin
Innovative Treatment Options and Selected Ongoing Clinical Trials in Urothelial Carcinoma8
Antibody–Drug
Conjugates
• Enfortumab vedotin
• Sacituzumab govitecan
• Trastuzumab deruxtecan
• Atezolizumab
• Avelumab
• Cetrelimab
• Durvalumab
• Ipilimumab
• Nivolumab
• Pembrolizumab
• Tremelimumab
Immune
Checkpoint Inhibitors
• Erdafitinib
• Infigratinib
• Pemigatinib
FGFR Inhibitors
• TAR-200
Intravesical
Devices
NORSE (NCT03473743) phase 2:
erdafitinib + cetrelimab vs erdafitinib
THOR (NCT03390504) phase 3:
erdafitinib vs chemo vs pembrolizumab in patients
with selected FGFR mutations
NCT03523572 phase 1b: trastuzumab
deruxtecan + nivolumab in HER2-expressing UC
TROPiCS-04 (NCT04527991) phase 3:
sacituzumab govitecan vs chemo
SunRISe-2 (NCT04658862) phase 3:
TAR-200 + cetrelimab vs chemo or RT
S1806 (NCT03775265) phase 3:
atezolizumab ± CRT in localized MIBC
ALBAN (NCT03799835) phase 3:
atezolizumab + BCG vs BCG
KEYNOTE-676 (NCT03711032) phase 3:
SunRISe-1 (NCT04640623) phase 2b:
TAR-200 + cetrelimab vs TAR-200 vs cetrelimab
pembrolizumab + BCG vs BCG
SWOG 1605 (NCT02844816) phase 2:
atezolizumab monotherapy
NCT04241185 phase 3:
pembrolizumab + CRT in MIBC
A Snapshot of Approved Therapies and
Ongoing Investigations in Urothelial Carcinoma
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/JKS40
1. Tecentriq (atezolizumab) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/761034s043lbl.pdf. 2. Bavencio (avelumab) Prescribing Information.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/761049s005lbl.pdf. 3. Opdivo (nivolumab) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/
label/2021/125554s097lbledt.pdf. 4. Keytruda (pembrolizumab) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/125514s113lbl.pdf. 5. Balversa (erdafitinib)
Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/212018s001lbl.pdf. 6. Padcev (enfortumab vedotin-ejfv) Prescribing Information. https://www.
accessdata.fda.gov/drugsatfda_docs/label/2021/761137s006s008lbl.pdf. 7. Trodelvy (sacituzumab govitecan-hziy) Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/
label/2021/761115s009lbl.pdf. 8. www.clinicaltrials.gov.