A real-world study finds only modest uptake of maintenance avelumab following its July 2020 FDA approval for advanced or metastatic urothelial carcinoma, despite its proven survival benefit.

Maintenance avelumab is indicated as maintenance treatment for advanced urothelial carcinoma that has responded or stabilized after first-line platinum-containing chemotherapy.

In the 22 months after FDA approval, 20.4% of patients treated with first-line chemotherapy and 24.3% of maintenance-eligible patients received maintenance avelumab, Ronac Mamtani, MD, MSCE, of the University of Pennsylvania in Philadelphia, and colleagues reported in JAMA Network Open.

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Using Flatiron Health’s nationwide database of mostly community oncology practices, the investigators identified 3507 patients with advanced or metastatic urothelial cancer who initiated first-line therapy, including 2340 during the preapproval period and 1167 during the postapproval period. FDA approval of maintenance avelumab for urothelial carcinoma was significantly associated with a 9.9% increase in the use of first-line carboplatin-based chemotherapy, but no change in the use of first-line cisplatin-based chemotherapy or first-line immune checkpoint inhibitor therapy, the investigators reported. For first-line immunotherapy, 42.8% of patients received pembrolizumab or atezolizumab.

“The limited use of immunotherapy in the maintenance setting stands in contrast to the rapid adoption of immunotherapy in the first-line setting (ie, pembrolizumab and atezolizumab), which could be due to limited clinician awareness of maintenance immunotherapy and/or patient preferences against long-term treatment after response to initial chemotherapy,” Dr Mamtani’s team wrote. “Our finding of higher treatment starts with carboplatin-based chemotherapy in the postmaintenance period suggests an increasing preference by clinicians of a treatment strategy that provides patients an opportunity for 2 effective treatment options.”

High use of first-line immunotherapy likely reflects use in patients ineligible for any platinum-containing chemotherapy.

Disclosure: This research was supported by Merck & Co. Please see the original reference for a full list of disclosures.


Mamtani R, Zhang H, Parikh RB, et al. Uptake of maintenance immunotherapy and changes in upstream treatment selection among patients with urothelial cancer. JAMA Netw Open. Published online April 14, 2023. doi:10.1001/jamanetworkopen.2023.8395