What is your preferred regimen for metastatic bladder adenocarcinoma?

Clinical trials, e.g. ICONIC (PI: Dr. Andrea Apolo) would be very interesting if slots are available. Outside trials, would consider FOLFOX (or FOLFIRI if neuropathy is an issue) as a 'colorectal-like' regimen (GI Med Onc can help manage regimen based on their experience). Dr. Siefker-Radtke had a trial with Gemzar/5FU/cisplatin that is not open now: NCT00082706.

Consider tumor NGS testing to assess targets, see relevant paper that we published in the past: Necchi et al., PMID 31959546. 

Given the absence of high level evidence (and the likelihood we will never have high level evidence), I would extrapolate from colorectal cancer and suggest FOLFOXIRI-bevacizumab in a fit patient (similar to advanced colorectal cancer). In those with suboptimal performance status or comorbidities, consider FOLFOX or FOLFIRI combined with bevacizumab. Genomics should be performed to guide subsequent therapy (including immune checkpoint inhibition for TMB>10 or MSI). Surgical resection (or stereotactic radiotherapy) should be considered for oligometastatic disease since systemic therapy alone is unlikely to be curative. Trials should be considered as salvage therapy guided by genomics.