How do you decide between maintenance avelumab vs CRT for patients with N2-3 bladder cancer who have SD or PR after platinum induction?

For patients with N2-N3 disease who have a clinical PR or SD with platinum-based chemotherapy, switch maintenance avelumab would be quite reasonable since such patients were eligible for the JAVELIN Bladder-100 phase III trial (and benefit was seen regardless of PD-L1 status, although benefit appeared more robust in PD-L1+ patients) that led to FDA approval. However, in selected fit patients, radiotherapy for the bladder primary and oligometastatic sites may be considered with or without concurrent chemotherapy and followed by subsequent maintenance avelumab. Notably, when examining patients in JAVELIN Bladder-100 based on prior CR/PR/SD, all groups appeared to benefit. Indeed, even in the group with prior CR, the median PFS with maintenance avelumab was only 7.4 months (Grivas P, et al. ESMO Congress 2020). Hence, I would lean toward maintenance avelumab even after chemoradiation in this patient. In those with more limited nodal metastases (usually N1-N2 but reasonable in selected fit N3 patients) who achieve a CR or near-CR with platinum-based chemotherapy, surgery may be considered (caveat is that this approach is based on benefit shown in retrospective evidence).