Pembrolizumab alone or combined with chemotherapy versus chemotherapy as first-line therapy for advanced urothelial carcinoma (KEYNOTE-361): a randomised, open-label, phase 3 trial

Efficacy and safety of BCG and immune checkpoint inhibitors in non-muscle invasive bladder cancer: A meta-analysis with exploratory chemotherapy comparisons

Bladder cancer (BC) is a significant global health concern and includes non-muscle-invasive BC (NMIBC), which poses challenges due to recurrence and progression. Immunotherapy, such as immune checkpoint inhibitors (ICIs) and Bacillus Calmette-Guérin (BCG), shows promise particularly in cases of BCG failure or BCG-unresponsive NMIBC, with ICIs emerging as a potential treatment option for these challenging cases. To the best of our knowledge, the present study is the first to systematically compare the efficacy and safety of BCG with ICIs in NMIBC. The present meta-analysis identifies response predictors and treatment outcomes, which can help in recognizing potential biomarkers such as tumor characteristics, hemoglobin levels and baseline performance status, associated with therapy response. These insights may guide future research in developing personalized treatment strategies for BCG non-responsive NMIBC cases. Following the Preferred Reporting Standards for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search identified relevant studies published between January 2015 and April 2024. Randomized controlled trials and clinical trials involving patients with BCG-refractory NMIBC were included in the primary analysis. Data extraction and analysis were conducted using Review Manager version 5.4, employing a random effects model. The risk of bias assessment followed the Cochrane guidelines. The present study included 2,154 participants across 10 studies evaluating treatments for NMIBC. Primary comparisons focused on BCG vs. ICIs: Pembrolizumab significantly improved tumor control (OR, 4.67; 95% CI, 1.43-15.25; P=0.01), progression-free survival (PFS; OR, 4.85; CI, 1.58-14.85; P=0.006), and overall survival (OS; OR, 3.61; CI, 1.28-10.19; P=0.02). Atezolizumab similarly outperformed BCG in metastatic disease (OR, 0.19; CI, 0.06-0.59; P=0.004) and lymph node involvement (OR, 0.43; CI, 0.20-0.93; P=0.03). ICIs exhibited a favorable safety profile vs. BCG, with fewer incidents of anemia (OR, 2.87; P=0.001) and diarrhea (OR, 1.79; P=0.03), despite higher rates of asthenia (OR, 7.33; P<0.00001) and pyrexia (OR, 3.26; P<0.00001). Exploratory comparisons with chemotherapy revealed pembrolizumab's advantages in terms of PFS (OR, 1.36; P=0.02) and OS (OR, 1.31; P=0.005), while atezolizumab improved metastatic control (OR, 0.54; P=0.0008). Heterogeneity was low for BCG comparisons (I2=0%) but high for chemotherapy (I2=81-95%). In conclusion, ICIs, particularly pembrolizumab and atezolizumab, demonstrate superior efficacy and safety over BCG in BCG-refractory NMIBC, supporting their use as first-line alternatives. These findings advocate for a paradigm shift in managing BCG-unresponsive disease, emphasizing personalized immunotherapy.

Advances in platinum-based cancer therapy: overcoming platinum resistance through rational combinatorial strategies

Platinum-based cancer therapy remains a cornerstone of first-line treatment for several solid tumours such as ovarian, testicular, and non-small cell lung cancers, where it has received regulatory approval as both monotherapy and combination regimens. However, the inevitable emergence of resistance has necessitated extensive preclinical and clinical efforts to develop rational platinum-based combinations. The most appealing candidates for combination therapy are those that offer additive and/or synergistic effects without undesirable overlapping toxicities. Whilst early strategies focussed on co-administration with cytotoxic chemotherapies, recent advances have shifted towards combinations with targeted therapies and immunotherapies, offering improved efficacy and durability of response. In this review, we provide a comprehensive analysis of recent clinical trials evaluating platinum-based combination strategies (excluding radiotherapy) and give an overview of trial concepts that will lead to more refined therapies for cancer. We also highlight emerging dual-drug codelivery nanosystems, platinum-based antibody-drug conjugates (ADCs), and multi-targeted platinum compounds with promising preclinical and/or clinical evidence. Beyond traditional drug pairings, the improved design strategies of new platinum compounds such as their incorporation into ADCs offer enhanced targeting and reactivity. Whilst promising preclinical examples like trastuzumab-Pt(II) and cetuximab-C8Pt(IV) bring optimism to combinatorial approaches, significant challenges including stability and controlled payload release remain to be addressed before clinical translation. By integrating advances in molecular profiling and rational drug development, platinum-based therapies continue to evolve, offering renewed optimism for overcoming drug resistance and improving patient outcomes, although challenges such as biomarker identification, toxicity management, and treatment costs remain to be fully addressed.

Avelumab maintenance in advanced urothelial carcinoma: real-world data from Northern Spain (AVEBLADDER study)

BACKGROUND

Before the incorporation of enfortumab vedotin with pembrolizumab, the standard of care for patients with locally advanced or metastatic urothelial carcinoma who do not progress after platinum-based chemotherapy was avelumab maintenance therapy, as demonstrated by the JAVELIN 100 trial. However, real-world European data remain scarce.

PATIENTS AND METHODS

AVEBLADDER is a retrospective study conducted at 14 hospitals in Northern Spain, including patients with locally advanced or metastatic urothelial carcinoma diagnosed between January 2021 and June 2023. Outcomes of overall survival (OS) and progression-free survival (PFS) were analyzed for patients treated with platinum-based chemotherapy, with and without subsequent avelumab maintenance therapy. non-avelumab patients. Median PFS was 11.33 months (95% CI: 10-13.6) with avelumab and 6.43 months (95% CI: 6-7.6) without. One-year OS probabilities were 81.6% vs. 45.6% (p < 0.001) in the avelumab and non-avelumab groups, respectively. No unexpected toxicities were reported.

CONCLUSIONS

Despite proven survival benefits, avelumab uptake in real-world practice is limited by barriers like access, reimbursement, and awareness. These findings align with JAVELIN 100 and underscore the need for further real-world studies to address treatment disparities.

Deciphering molecular pathways in urological cancers: a gateway to precision therapeutics

BACKGROUND

Urological cancers, including prostate, kidney, bladder, testicular, and penile cancers, pose a significant health challenge, particularly in their metastatic stages. Surgical interventions remain fundamental, but recent advancements in medical therapies like chemotherapy, immunotherapy, and targeted therapies have shown promise in improving patient outcomes.

AIM OF REVIEW

This review aims to explore the current landscape of targeted therapies in urological cancers, focusing on the role of key signaling pathways such as phosphatidylinositol 3-kinase/protein kinase B (PI3K/Akt), mechanistic (mammalian) target of rapamycin (mTOR), growth factor-related mechanisms, c-Mesenchymal-epithelial transition factor (c-Met)/ hepatocyte growth factor (HGF), programmed cell death protein 1 and its ligand programmed death-ligand 1 (PD-1/PD-L1), and steroid hormone receptor pathways in tumor progression and therapeutic resistance. Key scientific concepts of review Dysregulation of pathways like PI3K/Akt and mTOR contributes to tumorigenesis, metastasis, and resistance to treatment, underscoring their relevance as therapeutic targets. Tyrosine kinase inhibitors and immune checkpoint inhibitors have demonstrated efficacy but face challenges such as intrinsic resistance and treatment-related toxicities. Integrating insights from signaling pathway research with clinical practice holds potential for developing more effective treatment paradigms, enhancing the efficacy of targeted therapies, and improving survival rates for patients with urological cancers.

Non-Invasive Tumor Budding Evaluation and Correlation with Treatment Response in Bladder Cancer: A Multi-Center Cohort Study

The clinical benefits of neoadjuvant chemoimmunotherapy (NACI) are demonstrated in patients with bladder cancer (BCa); however, more than half fail to achieve a pathological complete response (pCR). This study utilizes multi-center cohorts of 2322 patients with pathologically diagnosed BCa, collected between January 1, 2014, and December 31, 2023, to explore the correlation between tumor budding (TB) status and NACI response and disease prognosis. A deep learning model is developed to noninvasively evaluate TB status based on CT images. The deep learning model accurately predicts the TB status, with area under the curve values of 0.932 (95% confidence interval: 0.898-0.965) in the training cohort, 0.944 (0.897-0.991) in the internal validation cohort, 0.882 (0.832-0.933) in external validation cohort 1, 0.944 (0.908-0.981) in the external validation cohort 2, and 0.854 (0.739-0.970) in the NACI validation cohort. Patients predicted to have a high TB status exhibit a worse prognosis (p < 0.05) and a lower pCR rate of 25.9% (7/20) than those predicted to have a low TB status (pCR rate: 73.9% [17/23]; p < 0.001). Hence, this model may be a reliable, noninvasive tool for predicting TB status, aiding clinicians in prognosis assessment and NACI strategy formulation.

A comprehensive review on targeting diverse immune cells for anticancer therapy: Beyond immune checkpoint inhibitors

Although immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, primary resistance and acquired resistance continue to limit their efficacy for many patients. To address resistance and enhance the anti-tumor activity within the tumor immune microenvironment (TIME), numerous therapeutic strategies targeting both innate and adaptive immune cells have emerged. These include combination therapies with ICIs, chimeric antigen receptor T-cell (CAR-T), chimeric antigen receptor macrophages (CAR-Ms) or chimeric antigen receptor natural killer cell (CAR-NK) therapy, colony stimulating factor 1 receptor (CSF1R) inhibitors, dendritic cell (DC) vaccines, toll-like receptor (TLR) agonists, cytokine therapies, and chemokine inhibition. These approaches underscore the significant potential of the TIME in cancer treatment. This article provides a comprehensive and up-to-date review of the mechanisms of action of various innate and adaptive immune cells within the TIME, as well as the therapeutic strategies targeting each immune cell type, aiming to deepen the understanding of their therapeutic potential.

Impact of baseline PD-L1 status in BCG naive nonmuscle invasive bladder cancer on outcomes and changes after BCG exposure

INTRODUCTION

While BCG remains standard of care adjuvant treatment for high-risk nonmuscle invasive bladder cancer (NMIBC), predicting response to BCG therapy is difficult. PD-L1 expression in the tumor microenvironment is a biomarker which may impact the efficacy of immunotherapy. The purpose of this study is to determine the predicative ability of PD-L1 for BCG-unresponsiveness in BCG-naïve high-risk NMIBC.

MATERIALS AND METHODS

We performed a retrospective review of high-risk NMIBC patients treated with BCG in the United States (108) and Israel (124) from 2008 to 2014. PD-L1 status of BCG-naïve specimens determined with Dako 22c3 assay (CPS > 0) at initial transurethral resection was correlated with outcomes, primarily BCG-unresponsiveness. The impact of BCG exposure on PD-L1 expression was analyzed in patients who had sequential tumor sampling.

RESULTS

Of 232 patients, 48 (21.6%) were BCG-unresponsive. PD-L1 expression was positive in 20 (9.2%) and in 5 (5.4%), 15 (14.3%), and 0 of Ta, T1, and CIS, respectively. In the US cohort, BCG-unresponsiveness occurred in 2 (14.3%) of PD-L1 positive and 36 (42.9%) of PD-L1 negative patients (P = 0.042). Tumors with baseline PD-L1 positivity were associated with a lower rate of BCG-unresponsiveness (OR 0.14; 95%CI 0.03-0.76). The predictive value of PD-L1 status in determining BCG-unresponsiveness was poor (AUC 0.57, 95%CI 0.46-0.69). Changes from PD-L1 negative to positive status after BCG exposure were observed, indicating a possible mechanism of resistance to BCG.

CONCLUSIONS

While PD-L1 status was an imperfect overall biomarker for BCG unresponsiveness, there was an association between initial PD-L1 expression and BCG response. Additionally, there was an upregulation of PD-L1 expression in BCG unresponsive specimens. These findings generate a hypothesis-generating discussion regarding the tumor immune-microenvironment and its response to BCG. Further investigation is necessary to better understand this interaction and its impact on tumor biomarker profiling and patient selection for combination therapy.

Survivorship outcomes in patients treated with immune checkpoint inhibitors: a scoping review

BACKGROUND

Immune checkpoint inhibitors (ICIs) have become a central part of cancer care. However, the survivorship outcomes in patients treated with ICIs are understudied. Therefore, we conducted a scoping review to evaluate the current status of the field and to establish research gaps regarding survivorship outcomes with ICIs in real-life cohorts.

METHODS

We used the Web of Science, PubMed, and Embase databases to systematically filter published studies with real-life cohorts from January 1, 2010, until October 19, 2022. Studies evaluating at least one survivorship outcome in ICI-treated patients were included.

RESULTS

A total of 39 papers were included. Quality of life (QoL) (n = 23), toxicity burden (n = 16), and psychosocial issues (n = 9) were the most frequently evaluated survivorship outcomes. Anti-PD-1/PD-L1 monotherapy and a response to treatment were associated with better QoL. In addition, the ICIs were associated with grade 3 or higher immune-related adverse events (irAEs) in 10-15% and late/long-term irAEs in 20-30% of the survivors. Regarding psychosocial problems, over 30% of survivors showed evidence of anxiety and depression, and 30-40% of survivors reported neurocognitive impairments.

CONCLUSION

The survivors treated with ICIs have impairments in most survivorship domains. Further research is needed to gather data on the understudied survivorship outcomes like late and long-term effects, fertility, financial toxicity, and return to work in survivors treated with ICIs.

IMPLICATIONS FOR CANCER SURVIVORS

Available evidence demonstrates that a significant portion of survivors treated with ICIs have a significant toxicity burden, lower QoL than the general population, and a high rate of psychosocial problems.

Expression of TIM-3 in transitional cell carcinoma: A comparative study of tissue and serum levels

OBJECTIVE

To evaluate the expression of TIM-3 in tissue and serum specimens of patients diagnosed with transitional cell carcinoma (TCC), and to assess the correlation between local tissue expression and systemic serum levels.

MATERIAL AND METHOD

A cross-sectional study was conducted at Khyber Medical University, Peshawar, Pakistan. A total of 74 tissue samples (49 TCC cases, 25 controls) and 42 serum samples (35 TCC, 7 controls) were analyzed based on non-probability convenient sampling. Tissue TIM-3 expression was assessed using immunohistochemistry (IHC), while soluble TIM-3 (sTIM-3) concentrations in serum were measured by enzyme-linked immunosorbent assay ELISA.

RESULTS

TIM-3 expression was found to be significantly higher in TCC tissue samples compared to controls (p < 0.001), and was associated with both higher tumor grade (p = 0.040) and stage (p = 0.008). Serum sTIM-3 concentrations were slightly elevated in TCC patients compared to healthy individuals, however, the difference was not statistically significant (p = 0.449). Also, no meaningful correlation was found between tissue TIM-3 expression and serum sTIM-3 levels (ρ = -0.119, p = 0.494).

CONCLUSION

Elevated TIM-3 expression in tumor tissue correlates with aggressive features of TCC, supporting its utility as a potential tissue-based biomarker. Serum sTIM-3, however, lacks diagnostic reliability and does not reflect tissue expression.

Combining Radiotherapy with Immune Checkpoint Inhibitors for the Management of Muscle-Invasive Bladder Cancer: A Comprehensive Systematic Review from the Y-ECI ROSC EORTC group

OBJECTIVE

This review aims to evaluate the efficacy and safety of combining immune checkpoint inhibitors (ICI) with RT in the treatment of non-metastatic MIBC, focusing on neoadjuvant and bladder preservation strategies.

EVIDENCE ACQUISITION

A systematic literature review was conducted from January 2000 to December 2023 using PubMed and Clinicaltrials.gov databases. Studies investigating outcomes after combining immunotherapy with RT for non-metastatic MIBC were selected. Data extraction included study identifiers, patient characteristics, intervention and control arm details, and primary outcomes.

EVIDENCE SYNTHESIS

Among 28 selected studies, diverse approaches were observed, including neoadjuvant and bladder preservation strategies. Neoadjuvant trials, such as RACE IT, explored the feasibility of combining ICI with RT before radical cystectomy, showing promising efficacy and safety outcomes. In bladder preservation strategies, completed as well as ongoing trials demonstrated acceptable toxicity profiles and promising early efficacy data for combining ICI with chemoradiotherapy or RT alone.

CONCLUSION

Combining ICI with RT holds significant promise as a treatment strategy for non-metastatic MIBC. Preliminary evidence suggests favorable efficacy and safety profiles, supporting further exploration and potential integration into standard care. Ongoing phase III trials will provide crucial insights into the comparative effectiveness of adding ICI to conventional definitive treatments. In the evolving landscape of MIBC management, the combination of ICI and RT has the potential to reshape therapeutic paradigms and improve outcomes for patients.

Efficacy of Using Dendritic Cells in the Treatment of Prostate Cancer: A Systematic Review

(1) The primary prostate cancer treatment involves androgen deprivation therapy, with or without chemotherapy. Immunotherapy has emerged as a promising strategy against cancer due to its ability to modulate the immune system, overcome immune evasion, and stimulate the attack on tumor cells. Thus, this review urges an exploration of the underlying mechanisms to validate the efficacy and safety of dendritic cell immunotherapy for prostate cancer treatment. (2) An extensive literature search identified 45 eligible studies in PubMed, Web of Science, SCOPUS, and Embase databases. Phase I and II clinical trials and in vitro studies (PROSPERO registration number CRD42024538296) were analyzed to extract information on patient selection, vaccine preparation, treatment details, and disease progression. (3) Despite significant variability in vaccine development and treatment protocols, vaccines were shown to induce satisfactory immune responses, including T-cell activation, increased CD4 and CD8 cell populations, upregulated expression of HLA-A2 and HLA-DR, enhanced migratory capacity of dendritic cells, and elevated interferon levels. Cytokine responses, particularly involving Interleukin 10 (IL-10) and Interleukin 12 (IL-12), varied across studies. Immunotherapy demonstrated potential by eliciting positive immune responses, reducing PSA levels, and showing an acceptable safety profile. However, side effects such as erythema and fever were observed. (4) The analyzed treatments were well-tolerated, but variability in clinical responses and side effects underscores the need for further research to optimize the efficacy and safety of this therapeutic approach.

A clinical study of RC48-ADC combined with PD-1 inhibitor in bladder preservation therapy for muscle-invasive bladder cancer (MIBC)-based on real-world data analysis

OBJECTIVES

This study aimed to evaluate the efficacy and safety of RC48-ADC combined with PD-1 inhibitors in bladder preservation therapy for muscle-invasive bladder cancer (MIBC), and to explore the differences in treatment outcomes between primary and recurrent cases, as well as patients at different clinical stages.

METHODS

A retrospective analysis was conducted on 32 patients with clinically non-metastatic MIBC who received ≥ 3 cycles of RC48-ADC combined with PD-1 inhibitor therapy. Clinical efficacy was assessed through integrated imaging and histopathological evaluations.

RESULTS

Among the 32 patients, the 1-year progression-free survival (PFS) rate was 84.4%, the objective response rate (ORR) was 68.8%, and the 1-year bladder preservation rate was 68.8%. The primary group was superior to the recurrent group in PFS (94.7% vs. 69.2%), ORR (78.9% vs. 53.8%), and 1-year bladder preservation rate (78.9% vs. 53.8%). Similarly, T2-stage patients exhibited better clinical responses than T3-stage patients in PFS (85.0% vs. 75.0%), ORR (80.0% vs. 54.5%), and 1-year bladder preservation rate (80.0% vs. 54.5%). Treatment-related adverse events (AEs) were predominantly grade I-II, with no severe immune-related complications reported.

CONCLUSIONS

The combination of RC48-ADC and PD-1 inhibitors significantly improves bladder preservation rates in MIBC patients with a favorable safety profile, particularly in primary and T2-stage cases. This regimen provides a personalized therapeutic strategy for patients unsuitable for conventional treatments.

Learning from the LEAP trial series: Optimizing clinical trial design for combination therapies

The LEAP trial series examining the synergy of pembrolizumab and lenvatinib across various cancers has yielded mixed results, highlighting the need for a more detailed understanding of combination therapies. By learning from these trials, we aim to advance the clinical development of more effective combination strategies to improve patient outcomes.

Breakthroughs and challenges of organoid models for assessing cancer immunotherapy: a cutting-edge tool for advancing personalised treatments

Organoid models are powerful tools for evaluating cancer immunotherapy that provide a more accurate representation of the tumour microenvironment (TME) and immune responses than traditional models. This review focuses on the latest advancements in organoid technologies, including immune cell co-culture, 3D bioprinting, and microfluidic systems, which enhance the modelling of TME and facilitate the assessment of immune therapies such as immune checkpoint inhibitors (ICIs), CAR-T therapies, and oncolytic viruses. Although these models have great potential in personalised cancer treatment, challenges persist in immune cell diversity, long-term culture stability, and reproducibility. Future developments integrating artificial intelligence (AI), multi-omics, and high-throughput platforms are expected to improve the predictive power of organoid models and accelerate the clinical translation of immunotherapy.

Antibody-drug conjugates in urothelial carcinoma: current status and future

PURPOSE OF REVIEW

Antibody-drug conjugates (ADCs) are quickly becoming frontline standard of care in many tumor types, including urothelial carcinoma. This review summarizes recent clinical investigations into the use of ADCs targeting nectin-4, trophoblast cell surface antigen-2 (Trop-2), human epidermal growth factor receptor 2 (HER-2), and other antigens in urothelial carcinoma.

RECENT FINDINGS

This review covers efficacy and toxicity data of ADCs alone and in combination with immunotherapy; mechanisms of resistance; and preclinical studies that provide biological basis for clinical approaches.

SUMMARY

Enfortumab vedotin and sacituzumab govitecan can be used in an unselected group of patients with urothelial carcinoma whereas HER-2 ADCs have only been administered in those with high expression or amplification. Most are being studied in combination with immune checkpoint inhibitors. Data supports use of enfortumab vedotin in combination with pembrolizumab as first-line therapy in metastatic/unresectable locally advanced urothelial carcinoma. Sacituzumab govitecan may be used as later-line option in these patients. HER-2 therapy is still under investigation but has many recent promising results.

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2025 Guidelines

BACKGROUND AND OBJECTIVE

This publication represents a summary of the updated 2025 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC). The aim is to provide practical recommendations on the clinical management of MMIBC with a focus on diagnosis, treatment, and follow-up.

METHODS

For the 2025 guidelines, new and relevant evidence was identified, collated, and appraised via a structured assessment of the literature. Databases searched included Medline, EMBASE, and the Cochrane Libraries. Recommendations within the guidelines were developed by the panel to prioritise clinically important care decisions. The strength of each recommendation was determined according to a balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence (including the certainty of estimates), and the nature and variability of patient values and preferences.

KEY FINDINGS AND LIMITATIONS

The key recommendations emphasise the importance of thorough diagnosis, treatment, and follow-up for patients with MMIBC. The guidelines stress the importance of a multidisciplinary approach to the treatment of MMIBC patients and the importance of shared decision-making with patients. The key changes in the 2025 muscle-invasive bladder cancer (MIBC) guidelines include the following: a new recommendation for the use of susceptible FGFR3 alterations to select patients with unresectable or metastatic urothelial carcinoma for treatment with erdafitinib; significant adaption and update of the recommendations for pre- and postoperative radiotherapy and sexual organ-preserving techniques in women; new recommendation related to radical cystectomy and extent of lymph node dissection based on the results of the SWOG trial; recommendation related to hospital volume; new recommendations for salvage cystectomy after trimodality therapy and for the management of all patients who are candidates for trimodality bladder-preserving treatment in a multidisciplinary team setting using a shared decision-making process; significant adaption and update to the recommendation for adjuvant nivolumab in selected patients with pT3/4 and/or pN+ disease not eligible for, or who declined, adjuvant cisplatin-based chemotherapy; and addition of a new recommendation for metastatic disease regarding the antibody-drug conjugate trastuzumab deruxtecan in case of HER2 overexpression; in addition, removal of the recommendations on sacituzumab govitecan as the manufacturer has withdrawn the US Food and Drug Administration approval for this product; update of the follow-up of MIBC; and full update of the management algorithms of MIBC.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This overview of the 2025 EAU guidelines offers valuable insights into risk factors, diagnosis, classification, treatment, and follow-up of MIBC patients and is designed for effective integration into clinical practice.

Enfortumab vedotin and pembrolizumab: redefining the standard of care for previously untreated advanced urothelial cancer

Combination treatment with Enfortumab vedotin (EV), an antibody drug conjugate targeting Nectin-4 with a monomethyl auristatin E (MMAE) payload, and pembrolizumab, a programmed death 1 (PD-1) inhibitor, has become the new standard of care for previously untreated locally advanced or metastatic urothelial carcinoma. In the recently published phase III study, EV-302, EV and pembrolizumab demonstrated improved outcomes compared to platinum-based chemotherapy, including objective response rate, progression free survival, and an unprecedented median overall survival of 33.8 months (versus 15.9 months; hazard ratio for death 0.51; 95% confidence interval 0.43-0.61; p < 0.00001). We reviewed the mechanism of action, clinical efficacy, exploratory biomarkers, and safety profile of EV and pembrolizumab as monotherapies and combination in urothelial cancer.

Bempegaldesleukin plus nivolumab in first-line advanced/metastatic urothelial carcinoma: Results from a phase II single-arm study (PIVOT-10)

BACKGROUND

In PIVOT-02, bempegaldesleukin (BEMPEG), a pegylated interleukin-2 cytokine prodrug, in combination with nivolumab (NIVO), a Programmed cell death protein 1 inhibitor, demonstrated the potential to provide additional benefits over immune checkpoint inhibitor monotherapy in patients with urothelial carcinoma, warranting further investigation. We evaluated BEMPEG plus NIVO in cisplatin-ineligible patients with previously untreated locally advanced or metastatic urothelial carcinoma.

METHODS

This open-label, multicenter, single-arm, phase II study enrolled patients with locally advanced/surgically unresectable or metastatic urothelial carcinoma and who were ineligible for cisplatin-based treatment. Patients received BEMPEG plus NIVO were administered intravenously every 3 weeks for ≤2 years or until progression or unacceptable toxicity. The primary endpoint was objective response rate (ORR) by blinded independent central review (BICR) in patients with low programmed death ligand-1 (PD-L1) expression. Secondary endpoints included ORR and duration of response in the overall population. Progression-free survival (PFS) and overall survival (OS) were exploratory endpoints.

RESULTS

One hundred and eighty-eight patients were enrolled; 123 patients were PD-L1 low (combined positive score [CPS] <10; 65.4%), 59 were PD-L1 high (31.4%; CPS ≥10), and 6 had PD-L1 status unknown (3.2%). ORR per blinded independent central review in patients with PD-L1-low tumors was 17.9% (95% confidence interval [CI] 11.6-25.8) while in all treated patients was 19.7% (95% CI 14.3-26.1). Median PFS and OS in the overall population were 3.0 months and 12.6 months, respectively. BEMPEG plus NIVO combination was well tolerated, with a safety profile similar to previously reported trials; no new or unexpected safety signals were reported.

CONCLUSIONS

BEMPEG plus NIVO did not meet the efficacy threshold for ORR in patients with previously untreated locally advanced or metastatic urothelial carcinoma and low PD-L1 expression.

Pre-treatment metastatic biopsy: a step towards precision oncology for urothelial cancer

Early metastatic spread and clonal expansion of individual mutations result in a heterogeneous tumour landscape in metastatic urothelial cancer (mUC). Substantial molecular heterogeneity of common drug targets, such as membranous NECTIN4, FGFR3 mutations, PDL1 or immune phenotypes, has been documented between primary and metastatic tumours. However, translational and clinical studies frequently do not account for such heterogeneity and often investigate primary tumour samples that might not be representative in patients with mUC. We propose this as a potential factor for why many biomarkers for mUC have failed to be integrated into clinical practice. Fresh pre-treatment metastatic biopsies enable the capturing of prevailing tumour biology in real time. The characterization of metastatic tumour samples can improve response prediction to immunotherapy, the anti-NECTIN4 antibody-drug conjugate enfortumab vedotin and the FGFR inhibitor erdafitinib. Routine metastatic biopsy can thus improve the precision of identifying driver druggable alterations, thus improving treatment selection for patients with mUC.

Treatment Efficacy and Molecular Dynamics of Neoadjuvant Durvalumab and Olaparib in Resectable Urothelial Bladder Cancer: The NEODURVARIB Trial

PURPOSE

Neoadjuvant treatment of bladder cancer is evolving, with immunotherapy demonstrating promising activity. PARP inhibition combined with immune activation has been proposed as a synergistic strategy. We conducted a comprehensive molecular characterization of tumors treated with this combination in the neoadjuvant setting to provide crucial results for rational development.

PATIENTS AND METHODS

A phase II clinical trial was designed to evaluate the combination of anti-PDL1 inhibitor durvalumab and PARP inhibitor olaparib, focusing on biomarker dynamics in both pre- and post-treatment settings. A total of 29 patients were enrolled. Genomic and transcriptomic profiling, as well as analyses of immune cell populations, was conducted at baseline and at the time of cystectomy.

RESULTS

Of the 29 patients treated, a pathologic complete response was observed in 13 cases (44.8%). No major safety concerns were associated with the treatment, and 26 patients (90%) underwent cystectomy. Mutational patterns, tumor mutation burden, and homologous recombination deficiency remained stable throughout treatment and were not predictive of outcomes. However, a shift toward stromal phenotypes and increased expression of epithelial-mesenchymal transition signatures were observed following therapy, particularly in resistant tumors. Moreover, an increase in circulating CD4+ CD27- CD28- T cells was noted among responders.

CONCLUSIONS

The combination of neoadjuvant durvalumab and olaparib shows therapeutic activity in bladder cancer. Resistance mechanisms seem to be driven by transcriptional adaptations rather than the emergence of new mutations.

Clinical development of immuno-oncology therapeutics

Immuno-oncology (IO) is one of the fastest growing therapeutic areas within oncology. IO agents work indirectly via the host's adaptive and innate immune system to recognize and eradicate tumor cells. Despite checkpoint inhibitors being only introduced to the market since 2011, they have become the second most approved product category. Current Food and Drug Administration (FDA)-approved classes of IO agents include: immune checkpoint inhibitors (ICIs), chimeric antigen receptor T-cell therapy (CAR-T), bi-specific T-cell engager (BiTE) antibody therapy, T-cell receptor (TCR) engineered T cell therapy, tumor-infiltrating lymphocyte (TIL) therapy, cytokine therapy, cancer vaccine therapy, and oncolytic virus therapy. Cancer immunotherapy has made progress in multiple cancer types including melanoma, non-small cell lung cancer (NSCLC), renal cell carcinoma (RCC), and urothelial carcinoma; however, several cancers remain refractory to immunotherapy. Future directions of IO include exploration in the neoadjuvant/perioperative setting, combination strategies, and optimizing patient selection through improved biomarkers.

Efficacy and safety of PD-1/PD-L1 inhibitor monotherapy or combination therapy versus platinum-based chemotherapy as a first-line treatment of advanced urothelial cancer: A systematic review and meta-analysis

Background

Recent clinical trials have shown that inhibitors targeting programmed cell death protein 1 (PD-1) or its ligand (programmed cell death-ligand 1 [PD-L1]) provide significant efficacy and clinical benefit in the treatment of advanced or metastatic urothelial carcinoma (UC). This systematic review and meta-analysis aimed to compare the effectiveness and safety of PD-1/PD-L1 inhibitors in combination with chemotherapy or PD-1/PD-L1 inhibitor monotherapy versus platinum-based chemotherapy as a first-line treatment for advanced UC.

Materials and methods

From the beginning of the database construction to February 4, 2024, a combination of medical subject headings and free-text words was searched using the Population Intervention Comparison Outcome Study design framework. The PubMed, Cochrane Library, Embase, and Web of Science electronic databases were searched. Meta-analyses of progression-free survival, overall survival, objective response rate (ORR), complete remission rate, duration of remission, and grade ≥3 adverse events were performed.

Results

Four studies were included in the meta-analysis. The PD-1/PD-L1 inhibitors plus chemotherapy therapy is associated with significantly better ORR compared with chemotherapy. Unfortunately, there were no significant differences between PD-1/PD-L1 inhibitor monotherapy and chemotherapy in terms of ORR, duration of remission, or overall survival.

Conclusions

Our findings indicate that PD-1/PD-L1 inhibitors plus chemotherapy therapy provides more oncological advantages than standard chemotherapy and should be recommended as a first-line treatment for advanced or metastatic UC. Attention must also be paid to the adverse effects of the combination of PD-1/PD-L1 inhibitors and chemotherapy.

Revealing the mechanisms and therapeutic potential of immune checkpoint proteins across diverse protein families

Host immune responses to antigens are tightly regulated through the activation and inhibition of synergistic signaling networks that maintain homeostasis. Stimulatory checkpoint molecules initiate attacks on infected or tumor cells, while inhibitory molecules halt the immune response to prevent overreaction and self-injury. Multiple immune checkpoint proteins are grouped into families based on common structural domains or origins, yet the variability within and between these families remains largely unexplored. In this review, we discuss the current understanding of the mechanisms underlying the co-suppressive functions of CTLA-4, PD-1, and other prominent immune checkpoint pathways. Additionally, we examine the IgSF, PVR, TIM, SIRP, and TNF families, including key members such as TIGIT, LAG-3, VISTA, TIM-3, SIRPα, and OX40. We also highlight the unique dual role of VISTA and SIRPα in modulating immune responses under specific conditions, and explore potential immunotherapeutic pathways tailored to the distinct characteristics of different immune checkpoint proteins. These insights into the unique advantages of checkpoint proteins provide new directions for drug discovery, emphasizing that emerging immune checkpoint molecules could serve as targets for novel therapies in cancer, autoimmune diseases, infectious diseases, and transplant rejection.

Cost-Effectiveness of Enfortumab Vedotin and Pembrolizumab for First-Line Metastatic Urothelial Cancer in the United States

OBJECTIVES

The EV-302 trial demonstrated that the combination of enfortumab vedotin and pembrolizumab (EV+P) significantly improved progression-free and overall survival in patients with metastatic urothelial cancer. However, the economic value of this regimen remains uncertain. Our study aims to evaluate the cost-effectiveness of EV+P versus platinum-based chemotherapy as first-line treatment for metastatic urothelial cancer from the US payer perspective.

METHODS

We developed a cohort state-transition model to simulate the lifetime costs and effectiveness of a cohort of 69-year-olds with metastatic urothelial cancer, resembling those in the EV-302 trial. Costs and utilities were derived from published literature to calculate the quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio for EV+P relative to chemotherapy. We conducted deterministic and probabilistic sensitivity analyses to identify factors influencing the cost-effectiveness.

RESULTS

In the base case, the chemotherapy strategy costs $80 874, yielding 1.26 QALYs and 1.69 life years. The EV+P strategy costs $752 637, yielding 2.54 QALYs and 3.31 life years. This resulted in an incremental cost-effectiveness ratio of $525 239/QALY and $414 927/life year. To achieve cost-effectiveness at a $150 000/QALY threshold, the price of the combination therapy would need to be reduced by 76%. A probabilistic sensitivity analysis indicated that EV+P was cost-effective in 0% of the simulations.

CONCLUSIONS

Although EV+P therapy is effective, it is not cost-effective at its current price as a first-line therapy in the United States at a cost-effectiveness threshold of $150 000/QALY. A substantial reduction in its drug cost is required to be cost-effective at commonly accepted willingness-to-pay thresholds.

Enhancing antitumor immunity: the role of immune checkpoint inhibitors, anti-angiogenic therapy, and macrophage reprogramming

Cancer treatment has long been hindered by the complexity of the tumor microenvironment (TME) and the mechanisms that tumors employ to evade immune detection. Recently, the combination of immune checkpoint inhibitors (ICIs) and anti-angiogenic therapies has emerged as a promising approach to improve cancer treatment outcomes. This review delves into the role of immunostimulatory molecules and ICIs in enhancing anti-tumor immunity, while also discussing the therapeutic potential of anti-angiogenic strategies in cancer. In particular, we highlight the critical role of endoplasmic reticulum (ER) stress in angiogenesis. Moreover, we explore the potential of macrophage reprogramming to bolster anti-tumor immunity, with a focus on restoring macrophage phagocytic function, modulating hypoxic tumor environments, and targeting cytokines and chemokines that shape immune responses. By examining the underlying mechanisms of combining ICIs with anti-angiogenic therapies, we also review recent clinical trials and discuss the potential of biomarkers to guide and predict treatment efficacy.

Lines of Therapy for Locally Advanced/Metastatic Urothelial Carcinoma: The New Paradigm

Urothelial carcinoma (UC) is the most common malignancy of the urinary tract, with urothelial bladder cancer accounting for approximately 90% of cases. Metastatic UC (mUC) is a particularly aggressive subset that presents significant treatment challenges, especially in patients who are often older than 70 years and have multiple comorbidities. For several decades, cisplatin-based chemotherapy has been the standard first-line treatment for locally advanced (LA) mUC. However, its utility has been limited as many patients are ineligible owing to their health status, and overall survival rates remain suboptimal. Recent advancements, including antibody-drug conjugates and immunotherapies, have begun to reshape the treatment landscape for LA/mUC. The combination of enfortumab vedotin and pembrolizumab has shown promising clinical outcomes. The approval of multiple novel drugs and combination therapies not only provides new opportunities for patient care but also creates the need for physicians to adapt to this evolving therapeutic paradigm. This review explores the latest clinical data on the management of LA/mUC and offers insights into sequencing therapies for patients with LA/mUC.

Different PD-L1 Assays Reveal Distinct Immunobiology and Clinical Outcomes in Urothelial Cancer

Testing for PD-L1 expression by IHC is used to predict immune checkpoint blockade (ICB) benefits but has performed inconsistently in urothelial cancer clinical trials. Different approaches are used for PD-L1 IHC. We analyzed paired PD-L1 IHC data on urothelial cancer samples using the SP142 and 22C3 assays from the phase III IMvigor130 trial and found discordant findings summarized by four phenotypes: PD-L1 positive by both assays, PD-L1 positive by the SP142 assay only, PD-L1 positive by the 22C3 assay only, and PD-L1 negative by both assays double negative. PD-L1 positive by both assays and PD-L1 positive by the SP142 assay only urothelial cancers were associated with more favorable ICB outcomes and increased dendritic cell (DC) infiltration. SP142 PD-L1 staining co-localized with DC-LAMP, a DC marker, whereas 22C3 staining was more diffuse. PD-L1 positive by the 22C3 assay only urothelial cancers, associated with worse outcomes, were enriched in tumor cell (TC)-dominant PD-L1 expression. Multiplex IHC in an independent ICB-treated cohort confirmed that TC-dominant PD-L1 expression was associated with shorter survival. Using different PD-L1 assays, we uncovered that SP142 may preferentially stain PD-L1-expressing DCs, key to orchestrating antitumor immunity, whereas TC-dominant PD-L1 expression, which underlies a subset of "PD-L1-positive" specimens, is associated with poor ICB outcomes. See related Spotlight by Karunamurthy and Davar, p. 454 .

A prognostic model for survival of patients with metastatic upper tract urothelial carcinoma with first-line systemic therapy

PURPOSE

Upper tract urothelial carcinoma (UTUC) presents distinct clinicopathological, molecular features, and biological behaviors compared to urothelial bladder carcinoma (UBC). Currently, no prognostic model exists for metastatic UTUC (mUTUC). This study aimed to develop a prognostic model for patients with mUTUC receiving first-line systemic therapy.

PATIENTS AND METHODS

A total of 476 patients with mUTUC who received first-line systemic therapy were included and retrospectively analyzed. Patients were randomly assigned to development and validation cohorts in a 3:1 ratio, with potential prognostic factors recorded prospectively. Univariate analyses identified clinical and laboratory factors significantly associated with median overall survival (mOS) in the development cohort, followed by multivariate analyses to determine independent prognostic factors. These factors were utilized to develop a prognostic model. Internal validation was conducted using the validation cohort.

RESULTS

The number of metastatic organs, Eastern Cooperative Oncology Group Performance Status (ECOG PS), time to distant metastasis (TTDM), white blood cell (WBC) count and alkaline phosphatase (ALP) were identified as independent prognostic factors for mUTUC. Patients were stratified into three risk categories: favorable (0 risk factors, mOS 65.0 months, 95% confidence interval [CI] 35.5-94.6]), intermediate (1 risk factor, mOS 32.0 months, 95% CI 25.8-38.2), and poor (2 + risk factors, mOS 16.0 months, 95% CI 12.1-19.9) (P < 0.001). The model's concordance statistic (c-statistic) was 0.71.

CONCLUSION

We developed and validated a prognostic model to estimate survival of patients with mUTUC receiving first-line systemic therapy. This model is applicable to real-world clinical practice and may inform the design of future clinical trials.

An evaluation of nivolumab plus gemcitabine and cisplatin in the treatment of advanced urothelial carcinoma

INTRODUCTION

For decades, first-line treatment for advanced/metastatic urothelial cancer has been platinum-based chemotherapy. However, many patients do not respond to platinum-based chemotherapy alone, and the vast majority do not have durable responses. While immune checkpoint blockade has demonstrated benefit in this setting, initial trials of concurrent chemotherapy and immune checkpoint blockade did not demonstrate improvements in overall survival.

AREAS COVERED

The recent CheckMate 901 trial compared gemcitabine, cisplatin, plus nivolumab to gemcitabine and cisplatin alone for first-line treatment of advanced/metastatic urothelial cancer. This was the first trial to demonstrate significant benefit in the combined chemotherapy and immune checkpoint blockade arm in advanced/metastatic urothelial cancer, most significantly showing an improvement in the primary outcomes of progression-free survival and overall survival, and the exploratory outcomes of objective response rate, complete response rate, and duration of complete response.

EXPERT OPINION

The combination of gemcitabine, cisplatin, plus nivolumab represents a new first-line treatment option for metastatic urothelial cancer. This article details the clinical benefit observed and how this establishes proof-of-concept for prior hypotheses related to the importance of the specific chemotherapy regimen combined with immune checkpoint blockade, revolving around immunomodulatory mechanisms of action of cisplatin, and synergy of these mechanisms with immunotherapy.

Retifanlimab in Advanced Penile Squamous Cell Carcinoma: The Phase 2 ORPHEUS Study

BACKGROUND AND OBJECTIVE

Patients with advanced penile squamous cell carcinoma (PSCC) have poor outcomes and very limited therapeutic options are available. Most PSCC cases have high PD-L1 expression, which is associated with worse prognosis. Immunotherapy targeting PD-L1 could benefit patients with PSCC. Our aim was to evaluate the efficacy and safety of the anti-PD-1 antibody retifanlimab in patients with advanced/metastatic PSCC.

METHODS

ORPHEUS was a single-arm, multicenter, phase 2 trial in 18 patients with advanced/metastatic PSCC, previously untreated with anti-PD-1/anti-PD-L1 agents. Patients received retifanlimab 500 mg intravenously every 4 wk for up to 2 yr. The primary endpoint was the objective response rate (ORR) according to Response Evaluation Criteria in Solid Tumors v1.1. Secondary endpoints included the clinical benefit rate (CBR), disease control rate, duration of response (DoR), time to response, progression-free survival (PFS), overall survival (OS), maximum tumor shrinkage, and safety. The Wilson method was used for the primary endpoint, and the Clopper-Pearson and Kaplan-Meier methods for secondary endpoints.

KEY FINDINGS AND LIMITATIONS

Median follow-up was 7.2 mo. The ORR was 16.7% (95% confidence interval [CI] 5.8-39.2); three patients had a partial response. Median DoR was 3.3 mo (range 1.8-8.5). The CBR was 22.2% (95% CI 6.4-47.6%). Median PFS was 2.0 mo (95% CI 1.6-3.3) and median OS was 7.2 mo (95% CI 3.0-9.8). One patient (5.6%) experienced grade 3 treatment-related adverse events (AEs). There were no grade >= 4 treatment-related AEs. The small sample size is the main limitation.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Single-agent retifanlimab exhibited signals of clinical activity in advanced/metastatic PSCC, with no new safety signals. Further investigation of retifanlimab in this setting is warranted.

PATIENT SUMMARY

Advanced penile cancer of the squamous cell type is a rare tumor with poor prognosis. The aggressiveness of this cancer is usually associated with high levels of a protein called PD-L1. We investigated whether retifanlimab, an immunotherapy drug against PD-1, has activity against this type of penile cancer. Tumor regression or stabilization occurred in one-third of the patients and the side effects were manageable.

Impact of Histology on Clinical Outcomes of Pembrolizumab Monotherapy in Patients With Advanced or Metastatic Urothelial Carcinoma in the Phase 3 KEYNOTE-045 and KEYNOTE-361 Trials

INTRODUCTION

A post hoc analysis of efficacy and safety outcomes with pembrolizumab monotherapy was conducted in patients with advanced or metastatic urothelial carcinoma (UC) with pure transitional cell carcinoma (TCC) or mixed predominant TCC histology enrolled in the phase 3 KEYNOTE-045 and KEYNOTE-361 studies.

METHODS

Adults with platinum-refractory advanced or metastatic UC who received pembrolizumab monotherapy in KEYNOTE-045 and adults with advanced or metastatic UC and no prior systemic chemotherapy who received pembrolizumab monotherapy in KEYNOTE-361 were analyzed separately. Pembrolizumab 200 mg was administered intravenously every 3 weeks for ≤2 years. Histology was assessed by investigator. End points included objective response rate (ORR), progression-free survival, and duration of response per RECIST v1.1 by central radiology assessment, as well as overall survival (OS) and safety.

RESULTS

In KEYNOTE-045, 268 patients had known histology (pure TCC: 186; mixed predominant TCC: 82). At data cutoff (October 1, 2020), median follow up was 62.9 months (range, 59.0-70.9). For pure TCC, confirmed ORR was 21.0% (95% CI, 15.4-27.5); median OS was 9.7 months (95% CI, 7.5-11.8). For mixed predominant TCC, confirmed ORR was 24.4% (95% CI, 15.6-35.1); median OS was 11.6 months (95% CI, 7.4-16.4). In KEYNOTE-361, 307 patients had known histology (pure TCC: 280; mixed predominant TCC: 27). At data cutoff (April 29, 2020), median follow-up was 32.5 months (range, 22.0-42.3). For pure TCC, confirmed ORR was 29.3% (95% CI, 24.0-35.0); median OS was 14.8 months (95% CI, 11.8-17.9). For mixed predominant TCC, confirmed ORR was 40.7% (95% CI, 22.4-61.2); median OS was 16.2 months (95% CI, 5.5-NR). Grade 3-5 treatment-related adverse events occurred at similar rates for treated patients in both studies.

CONCLUSION

In this post hoc analysis, efficacy and safety outcomes with pembrolizumab monotherapy were generally consistent for patients with advanced or metastatic UC in KEYNOTE-045 and KEYNOTE-361 studies between histology subgroups.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, KEYNOTE-045 (NCT02256436) and KEYNOTE-361 (NCT02853305).

Pembrolizumab Retreatment in Patients with Advanced or Metastatic Urothelial Carcinoma Who Responded to First-course Pembrolizumab-based Therapy

Patients with metastatic solid tumors who previously had stable disease or a response with immunotherapy may derive benefit from immunotherapy retreatment. This post hoc analysis evaluated pembrolizumab retreatment in patients with advanced/metastatic urothelial carcinoma who received pembrolizumab in KEYNOTE-045, KEYNOTE-052, or KEYNOTE-361, and either stopped pembrolizumab after a complete response (CR) or completed pembrolizumab (35 cycles [∼2 yr]) with an objective response or stable disease. Upon disease progression, protocol-specified pembrolizumab retreatment (200 mg intravenously every 3 wk) was administered for ≤17 cycles. Forty-nine patients met the criteria and were included. The median follow-up was 24.4 mo (range, 1.4-53.5). The median time between first-course therapy cessation and pembrolizumab retreatment was 10.7 mo (1.0-36.3). Twenty patients (41%) had an objective response with pembrolizumab retreatment, 65% of whom had a CR to first-course treatment. The median retreatment duration was 8.3 mo (range, 0.0-13.2); the median duration of response was 14.0 mo (2.1+ to 20.5). From retreatment initiation, the median (95% confidence interval) progression-free survival and overall survival were 9.5 mo (5.6-15.0) and 25.7 mo (21.5-27.5), respectively. Treatment-related adverse events occurred in 45% (grade 3-4: 6%; grade 5: 0%). Data suggest that pembrolizumab retreatment is beneficial and tolerable for some patients with advanced/metastatic urothelial carcinoma who previously had a CR or completed 2 yr of pembrolizumab.

Perioperative cisplatin-based chemotherapy for muscle-invasive bladder cancer: a decision analysis

PURPOSE

While meta-analyses of randomised studies suggest that neoadjuvant (NAC) or adjuvant (ACT) cisplatin-based chemotherapy improve overall survival in patients with muscle-invasive bladder cancer (MIBC), there are no trials comparing NAC against ACT in terms of quality-adjusted life years (QALYs) and costs. We aimed to evaluate the long-term QALYs, costs, and cost-effectiveness of different strategies for treating patients with MIBC.

METHODS

An individual-level state transition microsimulation model was developed for patients with urothelial non-metastatic MIBC eligible for surgery and NAC at diagnosis. Four treatment strategies were evaluated: (i) no treatment, (ii) radical cystectomy (RC) without perioperative chemotherapy, (iii) NAC followed by RC, and (iv) RC followed by ACT. Primary endpoints were QALYs and costs. Sensitivity analysis on the probability of being fit for ACT after surgery was conducted to account for the uncertainty of this parameter. The model was face-validated independently by two urologists.

RESULTS

Life-expectancy was 4.54 QALYs for ACT, 4.38 QALYs for NAC, 4.28 QALYs for RC without perioperative chemotherapy, and 2.84 QALYs for no treatment. Costs were lowest for ACT (US$45,805), compared to NAC (US$48,160), RC without perioperative chemotherapy (US$48,703), and no treatment (US$59,948). Sensitivity analysis suggested that NAC is associated with increased QALYs compared to ACT if the estimated probability of being fit for ACT is less than 38%. Limitations include the US-centric cost perspective.

CONCLUSIONS

In lack of comparative studies, simulated data suggests that ACT leads to increased QALYs and is cost-effective compared to NAC.

From Bench to Bladder: The Rise in Immune Checkpoint Inhibition in the Treatment of Non-Muscle Invasive Bladder Cancer

Non-muscle invasive bladder cancer (NMIBC) represents a significant clinical challenge due to its high recurrence rate and need for frequent monitoring. The current treatment modality is bacillus Calmette-Guérin (BCG) therapy combined with chemotherapy after transurethral resection of the bladder tumor (TURBT), which is highly effective in most patients. Yet, the cancer becomes resistant to these treatments in 30-40% of patients, necessitating the need for new treatment modalities. In the cancer world, the development of immune checkpoint inhibitors that target molecules, such as programmed cell death protein-1 (PD-1), its ligand, PD-L1, and Cytotoxic T-lymphocyte-associated protein-4 (CTLA-4), have revolutionized the treatment of many cancer types. PD-1/PD-L1 and CTLA-4 are shown to be upregulated in NMIBC in certain circumstances. PD-1/PD-L1 interactions play a role in immune evasion by suppressing T cell activity within the tumor microenvironment (TME), while the binding of CTLA-4 on T cells leads to downregulation of the immune response, making these pathways potential immunotherapeutic targets in NMIBC. This review seeks to understand the role of these therapies in treating NMIBC. We explore the cellular and non-cellular immune landscape in the TME of NMIBC, including Tregs, T effector cells, macrophages, B cells, and relevant cytokines. We also discuss the biological role of PD-1/PD-L1 and CTLA-4 while covering the rationale for these immunotherapies in NMIBC. Finally, we cover key clinical trials that have studied these treatments in NMIBC clinically. Such a study will be helpful for urologists and oncologists to manage patients with NMIBC more effectively.

Case Report: Pembrolizumab in a patient with preexisting paraneoplastic dermatomyositis and sarcomatoid urothelial carcinoma. Searching for balance

Dermatomyositis (DM) is an uncommon systemic autoimmune disorder classified as one of the idiopathic inflammatory myopathies (IIM). DM could also represent a manifestation of an underlying neoplasm with a relative risk of cancer globally ranging from 3% to 8%. Owing to the strong connection between immunosurveillance and cancer progression, the management of paraneoplastic DM represents a challenging issue. To complicate matters is the advent of cancer immunotherapy, that might interfere with self-tolerance with a true risk of previous autoimmune disorders re-exacerbation. We report the case of a 50-year-old patient with advanced urothelial bladder cancer and preexisting paraneoplastic DM treated with pembrolizumab. On the basis of our experience, previous paraneoplastic DM might not necessarily represent an absolute contraindication for ICIs treatment. Furthermore, this case might suggest a role of intravenous immunoglobulins (IVIG) in preventing DM reactivation, underling the importance of a multidisciplinary approach.

Disulfidptosis related immune genes drive prognostic model development and tumor microenvironment characterization in bladder urothelial carcinoma

The intricate nature and varied forms of bladder urothelial carcinoma (BLCA) highlight the need for new indicators to define tumor prognosis. Disulfidptosis, a novel form of cell death, is closely linked to BLCA progression, prognosis, and treatment outcomes. Our current goal is to develop a novel disulfidptosis-related immune prognostic model to enhance BLCA treatment strategies. Utilizing RNA-seq data from The Cancer Genome Atlas (TCGA) , which included 419 patients (19 normal, 400 tumor), we performed weighted gene co-expression network analysis (WGCNA) to identify disulfidptosis-associated immune genes. Through multivariate Cox regression, and the least absolute shrinkage and selection operator (LASSO) regularization, we established a disulfidptosis-related immune risk scoring system. A nomogram combining risk score and clinical features predicted prognosis. Model performance was validated through survival curve analysis and independent validation cohort. Immune checkpoints, cell infiltration, and tumor mutation load were assessed. Differential gene enrichment analysis was conducted. Prognostic genes were validated via in vitro experiments. Eight immune genes related to disulfidptosis were identified and verified in BLCA prognosis. A prognostic model outperformed previous ones in predicting overall survival (OS) for high- and low-risk groups. Patients with low-risk scores had higher OS rates and tumor mutation burden (TMB) compared to high-risk score patients. CD4 memory T cells, CD8 T cells, M1 macrophages, and resting NK cells were found to be higher in the low-risk group. Immune checkpoint inhibitor (ICI) treatment may be more effective for the low-risk score group. High-risk score group exhibited stronger correlation with cancer malignant pathways. Knocking out tumor necrosis factor receptor superfamily member 12 A (TNFRSF12A) inhibits BLCA cell proliferation and invasion while overexpressing it has the opposite effect. We constructed a novel risk score model that combines disulfidptosis and immune genes, demonstrating good prognostic prediction performance. We discovered and verified that the TNFRSF12A gene is an oncogene in BLCA, which may help provide personalized guidance for individualized treatment and immunotherapy selection for BLCA patients to a certain extent.

Real-world treatment patterns and clinical outcomes in patients with locally advanced or metastatic urothelial carcinoma in Germany: retrospective CONVINCE study

PURPOSE

CONVINCE is a retrospective medical chart review study that examined demographics, treatment patterns, and outcomes in patients who received first-line (1L) treatment for locally advanced or metastatic urothelial carcinoma (la/mUC) in Germany.

METHODS

Eligible patients were adults with confirmed la/mUC who received any systemic 1L anticancer treatment between January 1, 2019, and September 30, 2021, outside of a clinical trial. Patients were grouped by type of 1L treatment: platinum-based chemotherapy (PBC), immune checkpoint inhibitor (ICI), or other treatments. Follow-up was ≥ 6 months after end of PBC or start of ICI or other treatments. The primary objective was measurement of real-world progression-free survival (rwPFS).

RESULTS

Data were collected from 188 patients treated at 27 sites (hospitals or office-based practices). First-line treatment was PBC in 76.1% of patients, ICI in 19.1%, and other treatments in 4.8%. The most common PBC regimen was cisplatin + gemcitabine (72.7%), and the most common ICI was atezolizumab (44.4%); 4.2% of PBC-treated patients received avelumab 1L maintenance. In patients who received 1L PBC, ICI treatment, or other treatments, median (95% CI) rwPFS was 10.5 months (9.2-11.6), 12.6 months (8.9-22.9), and not evaluable; median (95% CI) real-world overall survival was 18.1 months (16.5-19.0), 15.9 months (11.1-24.5), and not evaluable; and objective response rates were 56.6%, 60.0%, and 83.3%, including complete response in 14.0%, 20.0%, and 0%, respectively.

CONCLUSION

PBC was the most common 1L treatment in patients with la/mUC in Germany, consistent with treatment guidelines. Future studies are needed to assess outcomes with newer treatments.

Individualizing first-line treatment for advanced urothelial carcinoma: A favorable dilemma for patients and physicians

The treatment landscape for patients with advanced urothelial carcinoma (UC) has evolved rapidly in recent years. In current guidelines, combination treatment with enfortumab vedotin plus pembrolizumab is the first-line (1L) standard of care, and other recommended 1L treatment options are platinum-based chemotherapy followed by avelumab as switch-maintenance treatment in patients without progression, or combination treatment with nivolumab, cisplatin, and gemcitabine for cisplatin-eligible patients only. Individual patients differ in terms of their health status, disease characteristics, expected toxicities, and treatment preferences; thus, a "one-size-fits-all" approach to treatment is unlikely to be optimal. The availability of several treatment options creates the potential for individualized treatment. In this review, we discuss factors that may be considered when selecting 1L treatment for patients with advanced UC, including efficacy and safety data from phase 3 trials and real-world studies, quality of life, patient priorities for treatment, patient and disease characteristics, treatment sequencing, biomarkers, and treatment access and cost. Patients and physicians should discuss the benefit-risk balance of all available 1L options to enable shared decision-making. Longer follow-up from clinical trials and additional real-world studies are needed to further inform treatment selection.

Therapeutic Advances in Bladder Preservation for BCG-Unresponsive Non-Muscle Invasive Bladder Cancer

PURPOSE

Bacillus Calmette-Guérin (BCG) has long been the standard treatment for preventing recurrence and progression following resection of high-risk non-muscle invasive bladder cancer (NMIBC). Unfortunately, recurrence or progression despite BCG induction and maintenance treatment have significant prevalence-a persistent issue in urologic oncology. Notable advancements in the development of alternative therapeutic options have become available and are in the pipeline. This review aims to provide an overview of the current treatment landscape for patients with BCG-unresponsive NMIBC, highlighting both existing and emerging therapies that are expected to become more widely available.

METHODS

A narrative review based on data collected through the end of 2024.

RESULTS

Several treatment options, aside from radical cystectomy (RC), are currently available or in promising stages of clinical trials. Many of these treatment modalities were granted Fast Track and Breakthrough Therapy status due to their initial success. These include novel chemotherapy regimens, immune checkpoint inhibitors, device-assisted therapies, and new intravesical and systemic agents. Combination therapies combining traditional treatments and newer approaches were explored.

CONCLUSIONS

The next few years promise to offer patients a variety of new, effective therapies for BCG-unresponsive NMIBC. These advancements hold significant potential for improving patient outcomes and providing more targeted, organ-sparing treatment options.

Effectiveness and safety of PD-1/L1 inhibitors as first-line therapy for patients with advanced or metastatic urothelial carcinoma who are ineligible for platinum-based chemotherapy: a meta-analysis

Objective

To evaluate the efficacy and safety of programmed cell death protein 1 or its ligand (PD-1/L1) inhibitors as first-line therapy in advanced or metastatic urothelial carcinoma (mUC) who are ineligible for platinum-based chemotherapy.

Method

A systematic search was conducted in four databases (Pubmed, Embase, Web of Science, and the Cochrane Library) to find articles that evaluate the effectiveness of first-line PD-1/L1 inhibitors for mUC, from the establishment of the databases to 22 November 2023. Meta-analyses were performed to evaluate the frequencies of progression-free survival (PFS), overall survival (OS), complete response (CR), partial response (PR), stable disease (SD), progressive disease (PD), objective response rate (ORR), disease control rate (DCR), and grade ≥ 3 treatment-related adverse events (trAEs).

Results

Totally six studies were included for meta-analysis. The CR, PR, SD, PD, ORR, DCR, and grade ≥ 3 trAEs rate were 0.06 [95% confidence interval (CI), 0.04 to 0.07], 0.22 (95% CI, 0.16 to 0.30), 0.27 (95% CI, 0.23 to 0.31), 0.31 (95% CI, 0.20 to 0.44), 0.28 (95% CI, 0.21 to 0.37), 0.57 (95% CI, 0.47 to 0.67) and 0.26 (95% CI, 0.14 to 0.40), respectively. The median PFS and OS were 4.5 months and 13.7 months, respectively. Subgroup analysis showed that PD-1/L1 inhibitors monotherapy had an ORR rate of 0.25 (95% CI, 0.21 to 0.29) and a DCR rate of 0.50(95% CI, 0.44 to 0.56), while PD-1/L1 dual immunotherapy had a better ORR rate of 0.33 (95% CI, 0.15 to 0.52) and a DCR rate of 0.65 (95% CI, 0.49 to 0.80). However, there was no significant difference in PFS and OS between the two groups.

Conclusion

The findings indicated that PD-1/L1 inhibitors could be used as a safe and viable first-line treatment option for patients with advanced or metastatic urothelial carcinoma who were not suitable candidates for platinum-based chemotherapy. Specifically, the combination of Enfortumab vedotin (EV) and pembrolizumab (Pembro) showed more effectiveness in treating patients compared to trials using the current standard treatment, suggesting that it could be a promising alternative treatment option.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024510152.

Phase Ib study of anti-PD-L1 monoclonal antibody socazolimab in combination with nab-paclitaxel as first-line therapy for advanced urothelial carcinoma

BACKGROUND

PD-1/PD-L1 immune checkpoint inhibitors (ICIs) have demonstrated activity in the post-platinum and platinum-ineligible settings for advanced urothelial carcinoma (aUC). As only around 50% of patients with aUC can tolerate platinum-containing treatment, treatments combining first-line ICIs with non-platinum drugs are urgently needed. Therefore, we assessed the safety and efficacy of the anti-PD-L1 monoclonal antibody Socazolimab in combination with nab-paclitaxel as first-line therapy in aUC (NCT04603846).

METHODS

This was a multi-center, single-arm, phase Ib study that enrolled patients with treatment-naive aUC. Patients received Socazolimab (5 mg/kg) and nab-paclitaxel (260 mg/m2) Q3w. The primary endpoint was safety and tolerability of the combination regimen. Second endpoints were the objective response rate (ORR) and progression-free survival.

RESULTS

Between September, 2020 and September, 2021, 20 patients with urothelial carcinoma were enrolled, arising from renal pelvis (5), bladder (8), and ureter (7). After a median follow-up of 17 months, the median number of treatment cycles was 12. No patients had dose limiting toxicity. All patients had treatment-related adverse events (TRAEs), most of which were grade 1 or 2. The common TRAEs (≥20%) were peripheral neurotoxicity, alopecia, rash, increased ALT, weight loss, weakness, pruritus, increased AST, increased γGT, increased ALP, neutropenia, emesis, and anorexia. Nine patients (45%) developed grade 3 TRAEs including peripheral neurotoxicity (30.0%), increased ALT (10.0%), and increased γGT (5.0%). Two patients (10%) discontinued treatment because of grade 3 mouth ulcer (n = 1) and grade 2 lung fibrosis (n = 1). No grade 4-5 TRAEs were observed. Among the 17 patients who had received at least one tumor assessment, ORR was 58.8% (95% CI, 32.9%-81.6%) and the median progression-free survival was 8.3 months (95% CI, 5.2-19.5). The median duration of response was 13.3 months (95% CI, 2.0-20.1), and the overall survival was 19.5 months (95% CI, 11.2-not reached).

CONCLUSION

Socazolimab combined with nab-paclitaxel has shown good safety and promising antitumor activity as first-line therapy in patients with advanced urothelial carcinoma.

The Relationship Between Response Rate and Survival Benefits in Randomized Immunotherapy Studies

Understanding the relationship between the Objective Response Rate (ORR) and survival outcomes, notably Progression-Free Survival (PFS) and Overall Survival (OS), is relevant for assessing the efficacy of regimens in oncology. We evaluate the relationship between ORR, PFS and OS in immuno-oncology (IO) trials. Data from 68 clinical trials submitted to the FDA were evaluated, examining immunotherapy regimens, notably immune checkpoint inhibitors such as anti-programmed death (ligand)-1 [anti-PD-(L)1], cytotoxic T-lymphocyte-associated protein-4 (CTLA-4) inhibitors and combination therapies [e.g., IO + IO, anti-PD-L1 + chemotherapy, anti-PD-L1 + CTLA-4, anti-PD-L1 + TKI (tyrosine kinase inhibitors)]. Studies were included based on their reporting of ORR, PFS, and OS. Of the 68 clinical trials reviewed, 55 were included in the analysis. The correlation between ORR and PFS was moderate across most immunotherapy regimens, indicating that ORR can serve as a useful predictor of short-term disease control. However, the correlation between ORR and OS was weaker, especially in trials including combination therapies, indicating that ORR alone may not reliably predict long-term survival outcomes. ORR predicts PFS better in first-line treatment but declines in later lines and remains a weak OS predictor overall. Differing degrees of correlation between ORR and survival metrics, particularly across treatment lines and combinations, are observed. While ORR can serve as a surrogate marker for PFS in IO trials, its utility in predicting OS is restricted and the interpretation of the relationship between ORR and PFS or OS is a key limitation. Rather, a decline in PFS with increasing ORR may reflect trial differences rather than a direct relationship. Future analyses should adopt better methodologies to capture these dynamics and focus on improving surrogate endpoints for immunotherapy to improve clinical trial design and patient outcomes.

Outcomes by Retrospective Eligibility for Maintenance Therapy of Patients With Advanced Urothelial Carcinoma: Post Hoc Analysis of the Phase 3 KEYNOTE-361 Trial

INTRODUCTION

The phase 3 KEYNOTE-361 trial of first-line pembrolizumab with or without chemotherapy versus chemotherapy alone in patients with locally advanced or metastatic urothelial carcinoma (la/mUC) completed enrollment before the approval of postchemotherapy maintenance avelumab for patients without progressive disease. This post hoc analysis evaluated the outcomes of patients who received chemotherapy alone in KEYNOTE-361 by retrospective eligibility for subsequent maintenance therapy.

PATIENTS AND METHODS

Patients in the chemotherapy alone arm were retrospectively categorized as maintenance eligible (received ≥4 cycles of chemotherapy and did not die or experience disease progression within 10 weeks of chemotherapy completion), maintenance ineligible (received <4 cycles of chemotherapy or had progressive disease or died within 0-10 weeks after completion of ≥4 cycles of chemotherapy), and indeterminate eligibility for maintenance therapy (if neither maintenance eligible or ineligible). End points included progression-free survival per Response Evaluation Criteria in Solid Tumors version 1.1 by blinded independent central review and overall survival from randomization (start of chemotherapy).

RESULTS

Median follow-up was 31.7 months (range, 22.0-42.3). Among 342 patients who received chemotherapy alone, 172 (50.3%) were maintenance eligible, 108 (31.6%) were maintenance ineligible, and 62 (18.1%) had indeterminate eligibility for maintenance therapy. The median progression-free survival was 9.0 months (95% CI 8.4-10.4) in maintenance-eligible patients, 5.1 months (4.2-6.0) in maintenance-ineligible patients, and 2.3 months (1.9-3.8) in the indeterminate group; median overall survival was 23.3 months (95% CI 19.4-26.1), 10.2 months (9.1-11.6), and 5.5 months (3.7-8.5), respectively.

CONCLUSION

This post hoc analysis suggests that a majority of patients with untreated la/mUC who initiated chemotherapy in a clinical trial may have been considered eligible for maintenance therapy and had favorable survival outcomes compared with those considered maintenance ineligible.

Cisplatin- or Carboplatin-Based Chemotherapy Plus Pembrolizumab in Advanced Urothelial Cancer: Exploratory Analysis From the Phase 3 KEYNOTE-361 Study

INTRODUCTION

KEYNOTE-361 evaluated first-line pembrolizumab with and without platinum-based chemotherapy versus chemotherapy alone in advanced or metastatic urothelial carcinoma. The primary end points of progression-free survival (PFS) or overall survival (OS) were not met. Exploratory analysis of efficacy by platinum agent (cisplatin or carboplatin) is reported.

PATIENTS AND METHODS

Eligible patients were randomly assigned 1:1:1 to receive pembrolizumab 200 mg intravenously every 3 weeks for ≤35 cycles with or without chemotherapy (gemcitabine with investigator's choice of either cisplatin or carboplatin) or chemotherapy alone. This exploratory subset analysis evaluated PFS and objective response rate (ORR) per RECIST v1.1 by blinded independent central review and OS for cisplatin- or carboplatin-based chemotherapy with versus without pembrolizumab for patients assigned to chemotherapy-containing arms of KEYNOTE-361.

RESULTS

Of 1010 patients enrolled, 703 were assigned to receive a chemotherapy-containing regimen (n = 312 cisplatin based; n = 391 carboplatin based). Median follow-up was 31.3 months. For cisplatin-based arms, with versus without pembrolizumab, median OS was 20.1 versus 16.4 months (HR 0.88, 95% CI, 0.67-1.15) and median PFS was 8.5 versus 7.1 months (HR 0.67, 0.51-0.89). ORR was 64.1% versus 48.7%, respectively. For carboplatin-based arms, with versus without pembrolizumab, median OS was 15.5 versus 12.3 months (HR 0.84, 95% CI, 0.67-1.06) and median PFS was 8.0 versus 6.7 months (HR 0.86, 0.68-1.09). ORR was 47.2% versus 41.8%, respectively. Among patients in the cisplatin-based versus carboplatin-based chemotherapy alone arms, 55.8% versus 41.8% received a subsequent antiprogrammed cell death protein 1/ligand 1 therapy. The addition of pembrolizumab did not significantly increase the incidence of adverse events reported.

CONCLUSION

Results suggest trends toward OS and PFS improvements with the addition of pembrolizumab to gemcitabine-platinum doublet over gemcitabine-platinum alone regardless of whether cisplatin or carboplatin was the chosen platinum agent. OS may have been influenced by active subsequent therapies.

Clinical Outcomes With Immune Checkpoint Inhibitors in Patients With FGFR2/3, MTAP or ERBB2 Genomic Alterations in Advanced Urothelial Carcinoma

BACKGROUND

FGFR2/3, MTAP and ERBB2 genomic alterations have treatment targets in advanced urothelial carcinoma (aUC). These alterations may affect tumor microenvironment and outcomes with immune checkpoint inhibitors (ICIs) in aUC.

PATIENTS AND METHODS

We identified patients with available genomic data in our multi-institution cohort of patients with aUC treated with ICI. Outcomes (observed response rate [ORR], progression-free and overall survival [PFS, OS]) with ICI were compared between patients with and without FGFR 2/3, MTAP, ERBB2 alterations. We compared ORR using logistic regression and PFS/OS using Cox proportional hazards.

RESULTS

Out of 1,514 patients, 276 (18%), 174 (11%) and 208 (14%) patients had known FGFR2/3, MTAP and ERBB2 alteration status, respectively. and were treated with ICI in 1L or 2 + L. In patients with (vs. without) FGFR2/3 alteration, ORR with ICI was 21% vs. 32% (OR 0.54; [95%CI 0.32-0.91]), PFS was significantly shorter in patients with FGFR2/3 alterations (HR = 1.36 [95%CI 1.03-1.80]; P=0.03); OS was not significantly different (HR = 1.22 [95%CI 0.86-1.47]). In patients with (vs. without) MTAP alteration, ORR with ICI was 25% versus 40% (OR 0.52 [95%CI 0.20-1.38]); PFS and OS were nonsignificantly different. In patients with (vs. without) ERBB2 alteration, ORR with ICI was similar (37% vs. 35%; OR 1.06; 95%CI 0.57-1.97); PFS and OS were significantly longer in patients with ERBB2 alteration [HR 0.63 (95%CI 0.41-0.95); P=0.03; HR 0.66, [95% CI 0.44-0.97]), respectively.

CONCLUSION

Our results support further evaluation of FGFR2/3, MTAP and ERBB2 alterations as putative biomarkers in patients with aUC treated with ICI.

Novel combination therapy for platinum-eligible patients with locally advanced or metastatic urothelial carcinoma: a systematic review and network meta-analysis

Recent phase 3 randomized controlled trials (RCTs) demonstrate the promising impact of immune checkpoint inhibitor (ICI)-based combination therapies on locally advanced or metastatic urothelial carcinoma (UC). However, comparative data on the efficacy and toxicity of different ICI-based combinations are lacking. This study aims to compare the efficacy of first-line ICI-based combination therapies for locally advanced or metastatic UC using phase 3 RCT data. In November 2023, three databases were searched for RCTs evaluating oncological outcomes in patients with locally advanced or metastatic UC who were treated with first-line ICI-based combination therapies. Network meta-analysis (NMA) was conducted to compare outcomes, including overall survival (OS), progression-free survival (PFS), objective response rates (ORRs), complete response rates (CRRs), and treatment-related adverse events (TRAEs). Subgroup analyses were based on PD-L1 status and cisplatin eligibility. The NMA included five RCTs. Enfortumab vedotin (EV) + pembrolizumab ranked the highest for improving OS (100%), PFS (100%), ORR (96%), and CRR (96%), followed by nivolumab + chemotherapy. EV + pembrolizumab combination superiority held across PD-L1 status and cisplatin eligibility. In patients who are cisplatin-eligible, EV + pembrolizumab significantly improved OS (HR: 0.68, 95%CI 0.47-0.99) and PFS (HR: 0.67, 95%CI 0.49-0.92) compared to nivolumab + chemotherapy. Durvalumab + tremelimumab was the safest combination for severe TRAEs, and EV + pembrolizumab ranked second. Our analyses support EV + pembrolizumab combination as a first-line treatment for locally advanced or metastatic UC. Thus, EV + pembrolizumab may become a guideline-changing standard treatment.

Reanalysis of Urothelial Cancer Chemoimmunotherapy Trials With Differential Censoring

Importance

Three similar phase 3 randomized clinical trials have investigated PD-1/PD-L1 (programmed cell death 1 protein/programmed cell death 1 ligand 1) inhibitors in combination with platinum-based chemotherapy vs chemotherapy alone as first-line treatment for advanced urothelial carcinoma (IMvigor130, atezolizumab; KEYNOTE-361, pembrolizumab; and CheckMate901, nivolumab). Only CheckMate901 reported overall survival (OS) benefit for the combination. The reason for these inconsistent results is unclear.

Objective

To explore whether differential censoring-that is, censoring imbalance between the study groups-is a possible explanation for these inconsistent findings.

Design, Setting, and Participants

This comparative effectiveness study involved a censoring analysis of data from IMvigor130, KEYNOTE-361, and CheckMate901, which enrolled patients between 2016 and 2022. Participants included patients in these 3 trials.

Exposure

Participation in 1 of the 3 trials.

Main Outcomes and Measures

The primary outcomes were censoring rates adjusted for treatment effects. Censoring rates were calculated from the Kaplan-Meier (KM) curves. When excess censoring in the control group of open-label trials was found, the hypothesis was that better-performing patients might be dropping out to seek alternative treatments; a sensitivity analysis was conducted in which their survival was assumed to be similar to that of the longest surviving patients in the control group. Treatment effects of the censoring-adjusted KM curves were calculated using the 2-sided log-rank test.

Results

The 3 trials involved a total of 2162 patients (1640 male [76%]; age range, 65-69 years) Analysis of progression-free survival (PFS) curves demonstrated no differential censoring in IMvigor130, but there was more than 30% excess censoring in the chemotherapy-only groups in KEYNOTE-361 and CheckMate901 trials. After sensitivity analysis, the PFS benefit was no longer significant in either study (KEYNOTE-361, adjusted hazard ratio [HR], 1.13 [95% CI, 0.95-1.35]; CheckMate901, adjusted HR, 1.17 [0.96-1.44]). Analysis of OS curves demonstrated no differential censoring in IMvigor130 or KEYNOTE-361, but there was more censoring in the chemotherapy-only group in CheckMate901. After sensitivity analysis, the OS benefit of adding nivolumab to chemotherapy was lost (before adjustment, HR, 0.77 [95% CI, 0.63-0.95]; P = .01; adjusted HR, 0.95 [95% CI, 0.77-1.17]; P = .64).

Conclusions and Relevance

In this comparative effectiveness study, differential censoring explained the inconsistent results reported in the evaluated trials. The term perceived-inferiority censoring is suggested to describe a phenomenon wherein better-performing patients are aware of their treatment and drop out to pursue alternative therapeutic options; it is possible that this occurred in the open-label KEYNOTE-361 and CheckMate901 trials. Such censoring confounds randomization and interpretation of clinical trials, since a larger experimental group is compared with a selected group of controls with poorer prognosis.

Immune-related and Common Adverse Events With Programmed Cell Death 1/Programmed Cell Death Ligand 1 inhibitors combined with other Anticancer Therapy for Solid Tumors: A Systematic Review and Meta-analysis

AIMS

The combination of programmed cell death 1 (PD-1)/programmed cell death ligand 1 (PD-L1) inhibitors and anticancer therapies has been in the spotlight in recent years. However, the risks associated with these combination therapies are not fully elucidated. The primary objective of this study was to evaluate the relative risk of organ-specific immune-related adverse events (irAEs) and common adverse events (AEs) in patients treated with PD-1/PD-L1 inhibitor-based combination therapies compared to those treated with PD-1/PD-L1 inhibitor monotherapy for solid tumors.

MATERIALS AND METHODS

An electronic database search was performed using ClinicalTrials.gov, Medline, and American Society of Clinical Oncology (ASCO)/European Society for Medical Oncology (ESMO) annual meeting libraries. We included randomized controlled trials designed to assess the safety of combination therapies using PD-1/PD-L1 inhibitors and other anticancer drugs. All the selected clinical studies included solid tumors and provided information on the incidence of nonserious and serious AEs. The quality of evidence was assessed using the Cochrane risk-of-bias tool. A meta-analysis was performed using random-effect models to pool the results.

RESULTS

The primary analysis included 16 relevant clinical studies comprising 4232 patients, of whom 2071 and 2161 patients received PD-1/PD-L1 inhibitor--based combination therapy and PD-1/PD-L1 inhibitor monotherapy, respectively. Serious organ-specific irAEs were infrequent, even when PD-1/PD-L1 inhibitors were combined with other anticancer drugs. The incidence of serious colitis was significantly higher in the combination therapy group than in the monotherapy group. Among the common AEs associated with PD-1/PD-L1 inhibitors, the incidence of serious pyrexia/fever, nonserious pyrexia/fever, fatigue, nausea, decreased appetite, vomiting, diarrhea, dyspnea, and rash significantly increased in the combination therapy group. In the subgroup analysis based on the modes of action of concomitant anticancer drugs, the combination of PD-1/PD-L1 inhibitors and DNA synthesis inhibitors significantly increased the risk of serious colitis compared to PD-1/PD-L1 inhibitor monotherapy.

CONCLUSION

Organ-specific irAEs occur infrequently when combinations of PD-1/PD-L1 inhibitors and other anticancer drugs are used. However, the risk of serious colitis and certain AEs is higher than that associated with PD-1/PD-L1 inhibitor monotherapy. Vigilant monitoring of AEs and implementation of appropriate clinical management strategies guided by the mode of action of the combination drugs are essential.

Immunogenicity of cell death and cancer immunotherapy with immune checkpoint inhibitors

While immunotherapy with immune checkpoint inhibitors (ICIs) has revolutionized the clinical management of various malignancies, a large fraction of patients are refractory to ICIs employed as standalone therapeutics, necessitating the development of combinatorial treatment strategies. Immunogenic cell death (ICD) inducers have attracted considerable interest as combinatorial partners for ICIs, at least in part owing to their ability to initiate a tumor-targeting adaptive immune response. However, compared with either approach alone, combinatorial regimens involving ICD inducers and ICIs have not always shown superior clinical activity. Here, we discuss accumulating evidence on the therapeutic interactions between ICD inducers and immunotherapy with ICIs in oncological settings, identify key factors that may explain discrepancies between preclinical and clinical findings, and propose strategies that address existing challenges to increase the efficacy of these combinations in patients with cancer.