Would you prefer FGFR inhibitor or second line immunotherapy in a patient with metastatic urothelial cancer of the bladder with FGFR mutation?

I would clearly prefer immunotherapy specifically with the use of pembrolizumab. I would measure the PDL1 CPS expression, where the impact is much greater. Phase 3 data clearly shows significantly improved survival compared to chemotherapy or BSC. This is the first positive trial in the second-line space and granted full approval in this space. True, we do not know if immunotherapy would be less effective with a driver mutation as in the lung cancer space but cannot assume this, particularly after chemotherapy failure. The data with the median overall survival is 10+ months but more importantly, there is a significant tail on the curve. The data with FGFR inhibitors is impressive, but only from a single-arm study, and we do not know if ther...

Ideally clinical trial is the preferred option. There are many trials including THOR phase 3 trial comparing erdafitinib vs chemoTx and erdafitinib vs pembrolizumab. In the absence of trials, erdafitinib seems a very attractive 2nd line option for patients with FGFR activating mutation or fusion, esp. with numerically higher ORR and longer PFS, however these are based on phase 2 non-randomized trial and should be interpreted with caution. Notable activity against liver mets and oral availability are also relevant factors. Copay, insurance coverage, potential AEs, need for eye exams, logistics of ordering as well as need for lab monitoring for dose titration may be issues for erdafitinib. On the other hand, pembrolizumab has level I evidence...