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ACCC spoke with providers from three cancer programs across the US about how their institutions have put ADCs into practice for patients with metastatic bladder cancer, focusing on multidisciplinary collaboration and data-driven adverse event management.
Antibody-drug conjugates (ADCs) are an emerging class of therapies that use a three-part structure to target certain cancers: a monoclonal antibody, a chemotherapy drug, and a chemical linker that joins them. In 2023, the FDA first approved an ADC as part of a combination regimen for certain patients with metastatic urothelial (bladder) cancer, and the indications have continued to expand since then.
Administering and managing toxicities associated with this innovative therapy requires an equally innovative approach to support patients. ACCC spoke with providers from three cancer programs across the US about how their institutions have put ADCs into practice for patients with metastatic bladder cancer. Discussions focused on operational rollouts at their institutions, sustainable plans for multidisciplinary collaboration, and lessons for peers interested in optimizing bladder cancer care using ADCs.
At the University of California, San Francisco (UCSF), the multidisciplinary team treating patients with bladder cancer uses a collaborative approach to ensure ADC implementation is coordinated, personalized, and patient centered. This approach is particularly important when managing skin toxicities and neuropathy, the most common adverse events (AEs) related to this treatment.
On the UCSF team, multidisciplinary collaborators include medical oncologists, advanced practice providers, pharmacists, and specialists from outside departments, including pulmonology, endocrinology, and dermatology. Terence Friedlander, MD, Professor of Medicine at UCSF, explained that each patient is assessed holistically to determine which specialties might need to be involved in that individual’s case. The team looks not only for signs of common toxicities related to ADCs but also for comorbidities and environmental exposures that may affect care.
Iva Colón, NP, a nurse practitioner who specializes in genitourinary medical oncology at UCSF, also commonly sees patients taking natural supplements that may interact with medical oncology therapies. Details like these can fall through the cracks if the care team does not share knowledge effectively. “It takes a village, and having that open and direct communication is key,” Colón said. She recommended asking patients at each appointment what they are taking and documenting the answer to stay on top of changes that may affect their quality of life while receiving ADCs.
Rocky Mountain Cancer Centers (RMCC) is a network of community practices in Colorado that got a head start implementing ADCs for bladder cancer by participating in early-phase clinical trials. “The challenge wasn’t learning the drug itself,” said Manojkumar Bupathi, MD, MS, President of RMCC. “The challenge was how you integrate the regimen into your treatment paradigm.”
For patients receiving ADCs and surgical intervention, both medical oncology and urology teams at RMCC are involved at each step of the process—from treatment planning through surveillance. Patients who experience severe toxicities related to ADCs as neoadjuvant therapy are likely to face a longer recovery. Urology and medical oncology collaborate to adjust the dosing structure or surgery schedule to set patients up for success post-op. Dr. Bupathi recommended close collaboration between these two teams and robust staff education on ADC toxicities as keys to success for perioperative implementation of this treatment.
Patients with bladder cancer receiving ADCs at MD Anderson Cancer Center were developing AEs that reduced quality of life and, in extreme cases, led to hospitalization. The institution took a data-driven approach to design management strategies that reduced the burden on both patients and the healthcare system.
Cindy Y. Jiang, MD, Assistant Professor at MD Anderson Cancer Center, explained that her team used retrospective data to determine when common AEs were likely to occur. Skin toxicities typically arose within the first two to four weeks of treatment, so the team added an extra appointment with a full-body skin exam at day eight to detect rashes early. Neuropathy was found to be a cumulative toxicity that built up over a median of three months. The research team used this data to develop algorithms for each toxicity that provide management recommendations based on the grade of severity. For the next phase of research, the team is collecting skin biopsies of ADC-related rashes and analyzing them with spatial transcriptomics to better understand the mechanisms driving this toxicity.
Dr. Jiang recommended that cancer programs interested in collecting and implementing data to improve their ADC toxicity management should start by identifying collaborators in dermatology and neurology. This step ensures that specialized resources are available as AEs arise. “It’s important to assemble this team before you start on any sort of journey, because as oncologists, we’re definitely not experts in skin rashes or neurological issues, and so you really need to rely heavily on those collaborators,” she said.
This program is supported by Pfizer and Astellas. To learn more, visit ACCC’s Bladder Cancer page.
