When do you consider for first-line atezolizumab for metastatic bladder cancer?

I see these patients in 2 groups, "cisplatin-ineligible" or "chemotherapy-ineligible”.

In the “cisplatin- ineligible” group one may consider a carboplatin-based regimen (carboplatin plus gemcitabine or carboplatin plus taxol) or atezolizumab.

In “chemotherapy-ineligible”, I consider both performance status and visceral versus non-visceral metastasis. For example, ECOG >2 and extensive visceral metastasis, I would favor hospice. If disease is confined to lymph nodes or PS 1-2 I may use atezolizumab.