Assessment of synergistic vs. independent drug activity for enfortumab vedotin and pembrolizumab in untreated advanced urothelial carcinoma.

BACKGROUND: The combination of enfortumab vedotin (EV) and pembrolizumab (EV+P) was recently approved as a first-line (1L) therapy for patients with advanced urothelial cancer (aUC). Preclinical studies have suggested that these 2 drugs synergize with one another to drive anti-tumor responses. However, it remains unknown whether EV and pembrolizumab demonstrate synergistic activity in a clinical setting.

METHODS: We analyzed progression-free survival (PFS) from the pivotal clinical trials evaluating EV and/or pembrolizumab as 1L therapy for aUC, focusing on cisplatin-ineligible patients. We computed predicted PFS for combination EV+P under a statistical model of independent drug action. We then compared predicted PFS to observed PFS to ascertain whether EV+P demonstrates synergistic vs. independent drug activity.

RESULTS: Predicted PFS for EV+P combination therapy, assuming independent action of EV and pembrolizumab, was clinically and statistically indistinguishable from observed PFS for EV+P in the EV-302 trial (HR = 1.04 [0.79-1.37], P = 0.76).

CONCLUSIONS: Among cisplatin-ineligible patients with untreated aUC, the observed clinical efficacy of combination EV+P is supported by a model of independent drug action. These findings suggest that distinct patient subgroups respond to EV and/or pembrolizumab. Identifying predictive biomarkers of response for each drug could reduce unnecessary toxicity arising from universal combination therapy, as patients could instead be selectively treated with whichever therapy is more likely to be effective.