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Avilez ND, Capibaribe DM, Reis LO. Experimental and New Approaches for Bladder Preservation in Intermediate and High-Risk Non-Muscle-Invasive Bladder Cancer (NMIBC). Res Rep Urol 2024; 16:89-113. [PMID: 38601921 PMCID: PMC11005851 DOI: 10.2147/rru.s452377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/08/2024] [Indexed: 04/12/2024] Open
Abstract
About 75% of bladder cancers are detected as non-muscle invasive. High-risk patients have high progression risk. Although the standard is transurethral resection of bladder tumor plus full dose intravesical BCG for one to 3 years, due to the high risk of progression, radical cystectomy may be considered in specific cases. Although radical cystectomy is still the best approach for high-grade NMIBC from an oncological perspective, its high morbidity and impact on quality of life motivate studies of new strategies that may reduce the need for cystectomy. We carried out a mini-review whose objectives were: 1 - to identify bladder-sparing alternatives that are being studied as possible treatment for patients with intermediate and high-risk NMIBC; 2 - understand the evidence that exists regarding success rate, follow-up, and side effects of different strategies. Several studies have sought alternatives for bladder preservation, including immunotherapy, intravesical chemotherapy, chemo-hyperthermia, antibody-drug conjugates, viral genetic therapy, and others with promising results. The selection of an optimal therapy for high-risk NMIBC that can reduce the need for cystectomy, with low toxicity and high efficacy, is of paramount importance and remains an issue, however, several known medications are being tested as bladder-preserving alternatives in this scenario and have shown promise in studies.
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Affiliation(s)
- Natália D Avilez
- UroScience, State University of Campinas, Unicamp, Campinas, São Paulo, Brazil
| | - Diego M Capibaribe
- UroScience, State University of Campinas, Unicamp, Campinas, São Paulo, Brazil
| | - Leonardo O Reis
- UroScience, State University of Campinas, Unicamp, Campinas, São Paulo, Brazil
- ImmunOncology, Pontifical Catholic University of Campinas, PUC-Campinas, São Paulo, Brazil
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Maroof H, Paramore L, Ali A. Theories behind Bacillus Calmette-Guérin failure in high-risk non-muscle-invasive bladder cancer and update on current management. CANCER PATHOGENESIS AND THERAPY 2024; 2:74-80. [PMID: 38601486 PMCID: PMC11002745 DOI: 10.1016/j.cpt.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/17/2023] [Accepted: 11/26/2023] [Indexed: 04/12/2024]
Abstract
Bladder cancer encapsulates a wide spectrum of disease severities, with non-muscle invasive bladder cancer (NMIBC) representing an entirely different entity from muscle-invasive disease. Bacillus Calmette-Guérin (BCG) is one of the most successful intravesical treatment methods for patients diagnosed. However, a considerable proportion of patients fail to respond to BCG treatment. Given the propensity for recurrence in patients with high-risk bladder cancer, these patients present with surgical dilemmas. There is currently no gold standard for salvage treatment post-BCG failure or unified definition as to what that means. In this review, we discuss the mechanisms of action and pathophysiology of BCG, potential theories behind BCG failure, and the scope of novel treatments for this surgical conundrum.
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Affiliation(s)
- Hanna Maroof
- Department of Urology, Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley GU16 7UJ, United Kingdom
| | - Louise Paramore
- Department of Urology, Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley GU16 7UJ, United Kingdom
| | - Ahmed Ali
- Department of Urology, Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley GU16 7UJ, United Kingdom
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Montgomery J, Lybbert D, Sana S, El-Zawahry A, Peabody J, Pearce T, Adams N, Deebajah M, Dynda D, Babaian K, Crabtree J, Delfino K, McVary K, Robinson K, Rao K, Alanee S. Urinary bother, Urinalysis, and Two-Year Efficacy Follow-Up Results of Phase I Trial of Intravesical Bacillus Calmette-Guérin Combined with Intravenous Pembrolizumab in Recurrent or Persistent High-Grade Non-Muscle-Invasive Bladder Cancer after Previous Bacillus Calmette-Guérin Treatment. Clin Genitourin Cancer 2024; 22:102059. [PMID: 38554570 DOI: 10.1016/j.clgc.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 02/18/2024] [Accepted: 02/19/2024] [Indexed: 04/01/2024]
Abstract
OBJECTIVE To report urinary bother, urinalysis changes, disease-free survival (DFS), and overall survival (OS) over 2 years for subjects enrolled in a phase I dose-escalation trial (NCT02324582) of intravesical Bacillus Calmette-Guérin (BCG) in combination with systemic pembrolizumab for recurrent or persistent high-grade non-muscle invasive bladder cancer (HGNMIBC). METHODS Eighteen patients consented to the study. Five were screen failures. Clinical activity was determined using cystoscopy and cytology with a biopsy of suspicious lesions. Urinalysis and International Prostate symptom score were assessed at pre-treatment, Week 10 (during combined BCG and pembrolizumab treatment), and 3 and 6 months from treatment completion. IPSS was analyzed using a mixed-model repeated measures analysis. A Chi-square test was used to compare urinalysis results at each interval. RESULTS The pathologic disease stage after restaging transurethral resection and before treatment was pTa in 6 (46.2%), CIS in 6 (46.2%), and pT1 in 1 (7.7%). There was no increase in reported urinary bother throughout treatment. Quality of life measurements demonstrated no change in subjective burden. On urinalysis, we did not observe significant differences at 3 months compared to baseline evaluation. At 12 months, the DFS and OS were 69.23% and 92.31%, respectively. At 24 months, the DFS and OS were 38.46% and 92.31%, respectively. CONCLUSIONS Treatment with BCG combined with intravenous pembrolizumab is not showing increased urinary bother or adverse urinalysis changes. Two-year response data is promising and await confirmation in the phase III study (Keynote 676).
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Affiliation(s)
- Jazzmyne Montgomery
- Southern Illinois University School of Medicine, Southern Illinois School of Medicine, Springfield, IL
| | - Daniel Lybbert
- Southern Illinois University School of Medicine, Southern Illinois School of Medicine, Springfield, IL
| | | | - Ahmed El-Zawahry
- Department of Urology, The University of Toledo Medical Center, Toledo, OH
| | | | | | | | | | - Danuta Dynda
- Southern Illinois University School of Medicine, Southern Illinois School of Medicine, Springfield, IL
| | - Kara Babaian
- Southern Illinois University School of Medicine, Southern Illinois School of Medicine, Springfield, IL
| | - Jane Crabtree
- Southern Illinois University School of Medicine, Southern Illinois School of Medicine, Springfield, IL
| | - Kristin Delfino
- Southern Illinois University School of Medicine, Southern Illinois School of Medicine, Springfield, IL
| | - Kevin McVary
- Loyola University Medical Center, Department of Urology, Maywood, IL
| | - Kathy Robinson
- Southern Illinois University School of Medicine, Southern Illinois School of Medicine, Springfield, IL
| | - Krishna Rao
- Southern Illinois University School of Medicine, Southern Illinois School of Medicine, Springfield, IL
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Garneau CA, Marcotte N, Lacombe L, Fradet Y, Fradet V, Pouliot F, Toren P, Lodde M. Salvage therapy for BCG failure with intravesical sequential gemcitabine and docetaxel in patients with recurrent NMIBC. Can Urol Assoc J 2024; 18:33-40. [PMID: 37931285 PMCID: PMC10841565 DOI: 10.5489/cuaj.8341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
INTRODUCTION Bacillus Calmette-Guérin (BCG) failure occurs in approximately 40% of patients with non-muscle-invasive bladder cancer (NMIBC) within two years. We describe our institutional experience with sequential intravesical gemcitabine and docetaxel (gem/doce) as salvage therapy post-BCG failure in patients who were not candidates for or declined radical cystectomy (RC). METHODS We retrospectively reviewed NMIBC patients with BCG failure who received gem/doce from April 2019 through October 2022 at the CHU de Québec-Université Laval. Patients received at least five weekly intravesical instillations according to published protocols. Patients who responded to gem/doce had maintenance instillations monthly for up to two years. Primary outcome was progression-free survival (PFS). Secondary outcomes included recurrence-free survival (RFS), cystectomy-free survival (CFS), cancer-specific survival (CSS), overall survival (OS), and treatment adverse events. Survival probabilities were estimated using the Kaplan-Meier method from the first gem/doce instillation. RESULTS Thirty-five patients with a median age of 78 years old were included in the study. The median followup time was 21 months (interquartile range 10-29). More than 25% of patients received two or more prior BCG induction treatments. Overall and MIBC PFS estimates at one year were 85% and 88%, and at two years, 60% and 70%, respectively. Adverse events occurred in 37% of the patients, but only two patients didn't complete the treatment due to intolerance. Three patients underwent RC due to cancer progression. OS was 94% at two years. CONCLUSIONS With 60% of PFS at two years, gem/doce appears to be a safe and well-tolerated option for BCG failure patients. Further studies are needed to justify widespread use.
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Affiliation(s)
- Charles-Antoine Garneau
- Division of Urology, Department of Surgery, CHU de Québec–Université Laval, Quebec City, QC, Canada
| | - Nathalie Marcotte
- Department of Pharmacy, Unité pour l’usage optimal du médicament et la recherche (UGMR), CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Louis Lacombe
- Division of Urology, Department of Surgery, CHU de Québec–Université Laval, Quebec City, QC, Canada
| | - Yves Fradet
- Division of Urology, Department of Surgery, CHU de Québec–Université Laval, Quebec City, QC, Canada
| | - Vincent Fradet
- Division of Urology, Department of Surgery, CHU de Québec–Université Laval, Quebec City, QC, Canada
| | - Frédéric Pouliot
- Division of Urology, Department of Surgery, CHU de Québec–Université Laval, Quebec City, QC, Canada
| | - Paul Toren
- Division of Urology, Department of Surgery, CHU de Québec–Université Laval, Quebec City, QC, Canada
| | - Michele Lodde
- Division of Urology, Department of Surgery, CHU de Québec–Université Laval, Quebec City, QC, Canada
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Black PC, Tangen CM, Singh P, McConkey DJ, Lucia MS, Lowrance WT, Koshkin VS, Stratton KL, Bivalacqua TJ, Kassouf W, Porten SP, Bangs R, Plets M, Thompson IM, Lerner SP. Phase 2 Trial of Atezolizumab in Bacillus Calmette-Guérin-unresponsive High-risk Non-muscle-invasive Bladder Cancer: SWOG S1605. Eur Urol 2023; 84:536-544. [PMID: 37596191 PMCID: PMC10869634 DOI: 10.1016/j.eururo.2023.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/04/2023] [Accepted: 08/03/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Although radical cystectomy (RC) is the standard of care for patients with bacillus Calmette-Guérin (BCG)-unresponsive high-risk non-muscle-invasive bladder cancer (NMIBC), many patients are ineligible for surgery or elect bladder preservation. OBJECTIVE To evaluate the efficacy and safety of atezolizumab in BCG-unresponsive high-risk NMIBC. DESIGN, SETTING, AND PARTICIPANTS This was a single-arm phase 2 trial in patients with BCG-unresponsive high-risk NMIBC who were ineligible for or declined RC. INTERVENTION Intravenous atezolizumab every 3 wk for 1 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was the pathological complete response (CR) rate for patients with carcinoma in situ (CIS) determined via mandatory biopsy at 6 mo. Event-free survival (EFS) at 18 mo for patients with non-CIS tumors and treatment-related adverse events (TRAEs) were key secondary endpoints. RESULTS AND LIMITATIONS Of 172 patients enrolled in the trial, 166 received at least one dose of atezolizumab (safety analysis) and 129 were eligible (efficacy analysis). Of the 74 patients with CIS, 20 (27%) experienced a CR at 6 mo. The median duration of response was 17 mo, and 56% (95% confidence interval [CI] 34-77%) of the responses were durable to at least 12 mo. The 18-mo actuarial EFS rate among 55 patients with Ta/T1 disease was 49% (90% CI 38-60%). Twelve of 129 eligible patients experienced progression to muscle-invasive or metastatic disease. Grade 3-5 TRAEs occurred in 26 patients (16%), including three treatment-related deaths. The study was limited by the small sample size and a high rate of patient ineligibility. CONCLUSIONS The efficacy of atezolizumab observed among patients with BCG-unresponsive NMIBC is similar to results from similar trials with other agents, but did not meet the prespecified efficacy threshold. Modest efficacy needs to be balanced with a significant rate of TRAEs and the risk of disease progression when considering systemic immunotherapy in early-stage bladder cancer. PATIENT SUMMARY We tested intravenous immunotherapy (atezolizumab) in patients with high-risk non-muscle-invasive bladder cancer that recurred after BCG (bacillus Calmette-Guérin) treatment. Although we found similar outcomes to previous trials, the benefit of this therapy is modest and needs to be carefully balanced with the significant risk of side effects. This trial is registered on ClinicalTrials.gov as NCT02844816.
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Affiliation(s)
| | | | | | - David J McConkey
- Johns Hopkins Greenberg Bladder Cancer Institute, Baltimore, MD, USA
| | | | | | - Vadim S Koshkin
- Helen Diller Family Cancer Center, University of California-San Francisco, San Francisco, CA, USA
| | | | | | | | - Sima P Porten
- Helen Diller Family Cancer Center, University of California-San Francisco, San Francisco, CA, USA
| | - Rick Bangs
- Bladder Cancer Advocacy Network, Pittsford, NY, USA
| | | | - Ian M Thompson
- University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Seth P Lerner
- Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
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Asimakopoulos AD, Kochergin M, Colalillo G, Fahmy O, Hassan F, Renninger M, Gallioli A, Gavrilov P, Gakis G. New Intravesical Agents for BCG-Unresponsive High-Risk Non-Muscle Invasive Bladder Cancer. Bladder Cancer 2023; 9:237-251. [PMID: 38993180 PMCID: PMC11181857 DOI: 10.3233/blc-230043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/22/2023] [Indexed: 07/13/2024]
Abstract
BACKGROUND With the exception of the FDA-approved valrubicin and pembrolizumab, there are no standard second-line treaments for BCG-unresponsive high-risk non-muscle invasive bladder cancer (NMIBC). OBJECTIVES To provide a systematic review of the novel intravesically administered therapeutic agents for the salvage treatment of BCG-unresponsive NMIBC. METHODS Online search of the PubMed, EMBASE and Web of Science databases was performed. The endpoints of this review were to evaluate the efficacy of the agents in terms of complete response rates (CR) and durability of CR, overall survival, recurrence-free survival and cancer-specific survival and to report on their toxicity profile. A search on Clinicaltrials.gov was performed to identify ongoing clinical trials. RESULTS 14 studies were included in this review. The critical clinical need for the development of an effective, safe and durable intravesical drug for the salvage treatment of high-risk NMIBC seems to be met mainly by intravesical gene therapy; in fact, data support the FDA-approved nadofaragene firadenovec as a potentially important therapeutic advancement in this context. Promising results are also being obtained by the combination of N-803/BCG and by innovative drug delivery systems. CONCLUSIONS Considering the plethora of novel intravesical treatments that have completed phase II evaluation, one can reasonably expect that clinicians will soon have at their disposal new agents and treatment options for BCG-unresponsive NMIBC. In the near future, it will be up to the urologist to identify, for each specific patient, the right agent to use, based on safety, results and cost-effectiveness.
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Affiliation(s)
| | - Maxim Kochergin
- Department of Urology and Neurourology, BG Unfallkrankenhaus Berlin, Berlin, Germany
| | - Gaia Colalillo
- Urology Unit, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Omar Fahmy
- Department of Urology, Universiti Putra Malaysia (UPM), Selangor, Malaysia
| | - Fahmy Hassan
- Department of Urology, King Salman Hospital (MOH), Riyadh, Saudi-Arabia
| | - Markus Renninger
- Department of Urology, Eberhard-Karls University Tuebingen, Tuebingen, Germany
| | | | - Pavel Gavrilov
- Department of Urology, Fundaciò Puigvert, Barcelona, Spain
| | - Georgios Gakis
- University Clinic and Polyclinic of Urology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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Abou Chakra M, Packiam VT, O'Donnell MA. Real-world efficacy of adjuvant single-agent intravesical gemcitabine for non-muscle invasive bladder cancer. Expert Opin Pharmacother 2023; 24:2081-2091. [PMID: 37842956 DOI: 10.1080/14656566.2023.2271396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/12/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Failure, intolerance, or shortage of bacillus Calmette-Guerin (BCG) treatment for patients with high-risk (HR) non-muscle invasive bladder cancer (NMIBC) leave many facing the prospect of radical cystectomy (RC). However, despite the lack of large-scale randomized controlled studies with single-agent intravesical gemcitabine (Gem), it has emerged as a popular salvage agent after BCG failure or even a treatment alternative to BCG. AREAS COVERED 1. Characterization of treatment regimen details pertaining to single-agent intravesical adjuvant Gem use among disease states of NMIBC characterized by risk and BCG exposure. 2. Comparison of safety and efficacy of Gem according to risk category, type of tumor (papillary vs. carcinoma in situ (CIS)), and tumor grades. EXPERT OPINION Two randomized studies in early BCG failure disease demonstrate that single-agent Gem has superior efficacy versus repeated BCG therapy or mitomycin C. Studies enrolling patients with predominantly papillary disease without CIS, intermediate-risk (IR) disease, and less BCG exposure appear to derive the highest benefits from adjuvant Gem in terms of recurrence and progression. However, studies with cohorts enriched for a predominance of CIS, HR disease and/or more extensive BCG failure have poorer 2-year recurrence free survival and a somewhat higher risk of progression and RC.
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Affiliation(s)
| | - Vignesh T Packiam
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey, New Jersey, USA
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Claps F, Pavan N, Ongaro L, Tierno D, Grassi G, Trombetta C, Tulone G, Simonato A, Bartoletti R, Mertens LS, van Rhijn BWG, Mir MC, Scaggiante B. BCG-Unresponsive Non-Muscle-Invasive Bladder Cancer: Current Treatment Landscape and Novel Emerging Molecular Targets. Int J Mol Sci 2023; 24:12596. [PMID: 37628785 PMCID: PMC10454200 DOI: 10.3390/ijms241612596] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/26/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Urothelial carcinoma (UC), the sixth most common cancer in Western countries, includes upper tract urothelial carcinoma (UTUC) and bladder carcinoma (BC) as the most common cancers among UCs (90-95%). BC is the most common cancer and can be a highly heterogeneous disease, including both non-muscle-invasive (NMIBC) and muscle-invasive (MIBC) forms with different oncologic outcomes. Approximately 80% of new BC diagnoses are classified as NMIBC after the initial transurethral resection of the bladder tumor (TURBt). In this setting, intravesical instillation of Bacillus Calmette-Guerin (BCG) is the current standard treatment for intermediate- and high-risk patients. Unfortunately, recurrence occurs in 30% to 40% of patients despite adequate BCG treatment. Radical cystectomy (RC) is currently considered the standard treatment for NMIBC that does not respond to BCG. However, RC is a complex surgical procedure with a recognized high perioperative morbidity that is dependent on the patient, disease behaviors, and surgical factors and is associated with a significant impact on quality of life. Therefore, there is an unmet clinical need for alternative bladder-preserving treatments for patients who desire a bladder-sparing approach or are too frail for major surgery. In this review, we aim to present the strategies in BCG-unresponsive NMIBC, focusing on novel molecular therapeutic targets.
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Affiliation(s)
- Francesco Claps
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.C.); (L.O.); (C.T.)
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (L.S.M.); (B.W.G.v.R.)
| | - Nicola Pavan
- Department of Surgical, Oncological, and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (N.P.); (G.T.); (A.S.)
| | - Luca Ongaro
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.C.); (L.O.); (C.T.)
| | - Domenico Tierno
- Department of Life Sciences, University of Trieste, 34127 Trieste, Italy;
| | - Gabriele Grassi
- Department of Medical, Surgery and Health Sciences, Hospital of Cattinara, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Carlo Trombetta
- Urological Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, 34149 Trieste, Italy; (F.C.); (L.O.); (C.T.)
| | - Gabriele Tulone
- Department of Surgical, Oncological, and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (N.P.); (G.T.); (A.S.)
| | - Alchiede Simonato
- Department of Surgical, Oncological, and Oral Sciences, University of Palermo, 90127 Palermo, Italy; (N.P.); (G.T.); (A.S.)
| | - Riccardo Bartoletti
- Department of Translational Research and New Technologies, University of Pisa, 56126 Pisa, Italy;
| | - Laura S. Mertens
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (L.S.M.); (B.W.G.v.R.)
| | - Bas W. G. van Rhijn
- Department of Surgical Oncology (Urology), Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands; (L.S.M.); (B.W.G.v.R.)
| | - Maria Carmen Mir
- Department of Urology, Hospital Universitario La Ribera, 46600 Valencia, Spain;
| | - Bruna Scaggiante
- Department of Life Sciences, University of Trieste, 34127 Trieste, Italy;
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9
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Kodera A, Mohammed M, Lim P, Abdalla O, Elhadi M. The Management of Bacillus Calmette-Guérin (BCG) Failure in High-Risk Non-muscle Invasive Bladder Cancer: A Review Article. Cureus 2023; 15:e40962. [PMID: 37503461 PMCID: PMC10369196 DOI: 10.7759/cureus.40962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
Non-muscle invasive bladder cancer (NMIBC) is a common urological malignancy, and bacillus Calmette-Guérin (BCG) therapy is the gold standard treatment in intermediate and high-risk groups. However, BCG failure occurs in a significant proportion of patients, emphasizing the need for effective alternative treatment modalities to address this burden. These treatments include immunotherapy, enhanced drug delivery, targeted therapy, device-assisted chemotherapy, vaccine therapy, and gene therapy, which show varying degrees of safety and efficacy. The objective of this review is to summarize the current evidence and ongoing research on these emerging therapies, offering insight into their potential for improving patient outcomes and quality of life. Although radical cystectomy remains the standard of care for high-risk NMIBC patients unresponsive to BCG, novel treatment modalities hold promise for the future management of this challenging patient population.
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Affiliation(s)
- Ahmed Kodera
- Urology, Worcestershire Acute Hopsitals NHS Trust, Worcester, GBR
| | - Mahmoud Mohammed
- Urology, Worcestershire Acute Hospitals NHS Trust, Worcester, GBR
- Surgical Oncology, South Egypt Cancer Institute, Assiut, EGY
| | - Paul Lim
- Urology, Worcestershire Acute Hospitals NHS Trust, Worcestershire, GBR
| | - Omer Abdalla
- Urology, Wirral University Hospital, Liverpool, GBR
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Seiler R, Egger M, De Menna M, Wehrli S, Minoli M, Radić M, Lyatoshinsky P, Hösli R, Blarer J, Abt D, Kruithof-de Julio M. Guidance of adjuvant instillation in intermediate-risk non-muscle invasive bladder cancer by drug screens in patient derived organoids: a single center, open-label, phase II trial. BMC Urol 2023; 23:89. [PMID: 37170307 PMCID: PMC10176900 DOI: 10.1186/s12894-023-01262-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/27/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND In intermediate-risk non-muscle invasive bladder cancer (NMIBC) clinical guidelines suggest an adjuvant instillation with a chemotherapeutic agent. However, the agent and regimen are not clearly defined. Worldwide, less than 15% of patients receive this adjuvant chemotherapeutic instillation. We recently developed a pipeline for the generation of patient derived organoids (PDO) in NMIBC. In this phase II trial, we aim to use our in vitro pipeline to select the most effective drug for chemotherapeutic instillation in NMIBC patients. METHODS Patients with first diagnosis of intermediate-risk NMIBC that are directed to transurethral resection of bladder tumor (TURBT) are enrolled. During TURBT, tumor is sampled, and specimens are directed to generate PDO. Once the PDO are formed, drug screens on them for Epirubicin, Mitomycin C, Gemcitabine and Docetaxel are performed. The drug with the highest antitumor activity in vitro will then be selected for 6 adjuvant intravesical instillations once weekly. Thereafter, patients are followed according to clinical guidelines by cystoscopy. DISCUSSION The aim of this trial is to use drug screens in PDO to precise treatment selection for adjuvant instillation therapies in patients with intermediate-risk NMIBC. The ultimate goal of this trial is to reduce the risk of cancer recurrence. In the future, we aim to conduct clinical multicenter trials with an increased sample size, a broader panel of compounds and a focus on the reduction of cancer recurrence by precision delivery of care. Trial registration NCT05024734.
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Affiliation(s)
- Roland Seiler
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland.
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland.
| | - Martin Egger
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
| | - Marta De Menna
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland
| | - Saskia Wehrli
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
| | - Martina Minoli
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland
| | - Martina Radić
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland
| | - Pavel Lyatoshinsky
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
- Department of Urology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | - Raphael Hösli
- Department of Pharmacy, Hospital Center Biel, Biel, Switzerland
| | - Jennifer Blarer
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
| | - Dominik Abt
- Department of Urology, Hospital Center Biel, Spitalzentrum Biel, Vogelsang 84, 2501, Biel, Switzerland
| | - Marianna Kruithof-de Julio
- Department for BioMedical Research, Translational Organoid Resource Core, University of Bern, Bern, Switzerland
- Department for BioMedical Research, Urology Research Laboratory, University of Bern, 3008, Bern, Switzerland
- Department of Urology, Inselspital, Bern University Hospital, 3010, Bern, Switzerland
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11
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Kawada T, Yanagisawa T, Araki M, Pradere B, Shariat SF. Sequential intravesical gemcitabine and docetaxel therapy in patients with nonmuscle invasive bladder cancer: a systematic review and meta-analysis. Curr Opin Urol 2023; 33:211-218. [PMID: 36482766 DOI: 10.1097/mou.0000000000001065] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Shortages in intravesical Bacillus Calmette-Guérin (BCG) immunotherapy represent a challenge in the management of high-risk nonmuscle invasive bladder cancer (HR-NMIBC). This study aimed to review the efficacy and safety of intravesical gemcitabine (GEM) and docetaxel (DOCE) for BCG-naive and unresponsive HR-NMIBC. RECENT FINDINGS We identified six studies eligible for quantitative analysis through a systematic search according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement. In the two studies in the BCG-naive setting, 1-year and 2-year pooled recurrence-free survival (RFS) were 86 and 84%, respectively. In the two studies in the BCG unresponsive setting, 6-month, 1-year and 2-year pooled high-grade recurrence-free survival (HG-RFS) were 80, 66 and 51%, respectively. Cumulative data from four studies revealed that 2.3% of patients could not complete induction therapy and 6.9% experienced treatment delay or dose reduction due to adverse events. SUMMARY Despite the preliminary data and based on a small sample size, intravesical GEM/DOCE therapy is a highly promising combination yielding an effective and well tolerated alternative to BCG when indicated. Further large, well designed comparative studies with BCG are needed.
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Affiliation(s)
- Tatsushi Kawada
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama
| | - Takafumi Yanagisawa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama
| | - Benjamin Pradere
- Department of Urology UROSUD, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
- Division of Urology, Department of Special Surgery, The University of Jordan, Amman, Jordan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Urology, Weill Cornell Medical College, New York, New York, USA
- Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
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12
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Jeong SH, Ku JH. Treatment strategies for the Bacillus Calmette-Guérin-unresponsive non-muscle invasive bladder cancer. Investig Clin Urol 2023; 64:103-106. [PMID: 36882168 PMCID: PMC9995951 DOI: 10.4111/icu.20230042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Affiliation(s)
- Seung-Hwan Jeong
- Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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13
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Mullapudi SS, Rahmat JN, Mahendran R, Lim YK, Ong LT, Wong KY, Chiong E, Kang ET, Neoh KG. Tumor-targeting albumin nanoparticles as an efficacious drug delivery system and potential diagnostic tool in non-muscle-invasive bladder cancer therapy. NANOMEDICINE : NANOTECHNOLOGY, BIOLOGY, AND MEDICINE 2022; 46:102600. [PMID: 36064034 DOI: 10.1016/j.nano.2022.102600] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 08/16/2022] [Accepted: 08/24/2022] [Indexed: 06/15/2023]
Abstract
Current intravesical chemotherapy for non-muscle invasive bladder cancer (NMIBC) has limited efficacy due to loss of the instilled agent from urine voiding and the agent's lack of specificity for the tumors. We developed a nanocarrier (txCD47-HNP, ∼100 nm) based on human serum albumin conjugated with a peptide that targets the cluster of differentiation 47 receptor overexpressed on bladder cancer (BC) cells. The IC50 of gemcitabine elaidate (GEM) loaded in the txCD47-HNP was almost an order of magnitude lower than that of free GEM. In a mouse orthotopic BC model, GEM loaded in txCD47-HNP effectively reduced the tumor burden. Tumor cells in BC patients' urine can also be targeted by fluorescence-labeled txCD47-HNP resulting in >83 % of the cells exhibiting fluorescence. Thus, txCD47-HNP can potentially be a theranostic agent in NMIBC management by serving as a targeted drug delivery vehicle as well as an alternative to urine cytology.
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Affiliation(s)
- Sneha Sree Mullapudi
- Department of Biomedical Engineering, National University of Singapore, Kent Ridge 117583, Singapore
| | - Juwita Norasmara Rahmat
- Department of Biomedical Engineering, National University of Singapore, Kent Ridge 117583, Singapore
| | - Ratha Mahendran
- Department of Surgery, National University of Singapore, Kent Ridge 119228, Singapore
| | - Yew Koon Lim
- Department of Surgery, National University of Singapore, Kent Ridge 119228, Singapore
| | - Lee Ting Ong
- Department of Surgery, National University of Singapore, Kent Ridge 119228, Singapore
| | - Kah Ying Wong
- Department of Surgery, National University of Singapore, Kent Ridge 119228, Singapore
| | - Edmund Chiong
- Department of Surgery, National University of Singapore, Kent Ridge 119228, Singapore; Department of Urology, National University Hospital, Kent Ridge 119074, Singapore
| | - En-Tang Kang
- Department of Chemical and Biomolecular Engineering, National University of Singapore, Kent Ridge 117585, Singapore
| | - Koon Gee Neoh
- Department of Chemical and Biomolecular Engineering, National University of Singapore, Kent Ridge 117585, Singapore.
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14
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Reike M, Ingersoll M, Müller D, Zuiverloon T, Strandgaard T, Kamat A, Williams S, Seiler R, Todenhöfer T, Dyrskjøt L, Nawroth R, Goebell P, Schmitz-Dräger B, Sfakianos J, Meeks J, Horowitz A, Black P. Biology of BCG response in non-muscle invasive bladder cancer - 2021 IBCN Updates Part III. Urol Oncol 2022; 41:211-218. [PMID: 36266219 DOI: 10.1016/j.urolonc.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/15/2022] [Indexed: 11/05/2022]
Abstract
Bacillus Calmette-Guerin (BCG) remains the only FDA-approved first-line therapy in patients with high-risk non-muscle invasive bladder cancer. Recurrences, even after adequate BCG therapy, are common and the efficacy of second-line therapies remains modest. Therefore, early identification of patients likely to recur and treatment after recurrence remain critical unmet needs in the clinical care of bladder cancer patients. To address these deficits, a better understanding of the mechanisms of resistance to BCG-therapy is needed. The virtual update of the International Bladder Cancer Network (IBCN) on the biology of response to BCG focused on potential mechanisms and markers of resistance to intravesical BCG therapy. The insights from this meeting will be highlighted and put into context of previously reported mechanisms of resistance to BCG in this review.
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15
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Multi-Institution Evaluation of Sequential Intravesical Gemcitabine and Docetaxel in the Treatment of Bacillus Calmette-Guerin Naïve Patients with Non-Muscle Invasive Bladder Cancer. Clin Genitourin Cancer 2022. [DOI: 10.1016/j.clgc.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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16
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Freudenburg E, Bagheri I, Srinivas S, Martinez A, Putluri N, Klaassen Z, Kamat AM, Konety BR, Kim WY, Dyrskjøt L, McConkey DJ, Freedland SJ, Black PC, Daneshmand S, Catto JWF, Williams SB. Race reporting and disparities regarding clinical trials in bladder cancer: a systematic review. Cancer Causes Control 2022; 33:1071-1081. [PMID: 35699798 DOI: 10.1007/s10552-022-01593-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/21/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To systematically review the literature to investigate racial disparities among bladder cancer clinical trial enrollees. METHODS A systematic review was conducted using Ovid, MEDLINE® to identify clinical trials between 1970 and 2020. Articles were reviewed and were included if they assessed race in their outcomes reporting among bladder cancer patients enrolled in clinical trials. The review was conducted in accordance with the PRISMA statement. RESULTS We identified 544 clinical trials meeting our initial search criteria, with only 24 (4.4%) studies reporting racial demographic data. Enrollees were largely Caucasian (81-98%), with a strikingly small proportion of enrolled patients consisting of African-Americans (2-8%) and Hispanics (2-5%). Only one of the studies reported results on the efficacy and safety/tolerability of the tested treatment separately for racial groups and performed analyses stratified by race. CONCLUSION Race is poorly studied in bladder cancer clinical trials. Trial cohorts may not reflect multicultural populations. The potential association between race and efficacy, safety or tolerability of the tested interventions is unknown. Given the up to twofold increase in bladder cancer-specific death among African-Americans, further research is needed to address the impact of race in clinical trials, while encompassing socioeconomic factors and disease risk factor exposures.
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Affiliation(s)
- Elliott Freudenburg
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Iyla Bagheri
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Sunay Srinivas
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Ariza Martinez
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Nagireddy Putluri
- Department of Molecular and Cellular Biology, Dan L. Duncan Cancer Center, Advanced Technology Core, Alkek Center for Molecular Discovery, Baylor College of Medicine, Houston, TX, USA
| | - Zachary Klaassen
- Department of Surgery, Section of Urology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Badrinath R Konety
- Virginia Piper Cancer Center and Piper Breast Centers, Allina Health Cancer Institute, Minneapolis, MN, USA
| | - William Y Kim
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Lars Dyrskjøt
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - David J McConkey
- Johns Hopkins Greenberg Bladder Cancer Institute, Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA
| | | | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Siamak Daneshmand
- Department of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Stephen B Williams
- Department of Surgery, Division of Urology, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA.
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17
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Alanee S, El‐Zawahry A. Robotic‐assisted partial cystectomy for muscle invasive bladder cancer: Contemporary experience. Int J Med Robot 2022; 18:e2390. [DOI: 10.1002/rcs.2390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Shaheen Alanee
- Department of Urology Michigan State University The Detroit Medical Center Detroit Michigan USA
| | - Ahmed El‐Zawahry
- Department of Urology The University of Toledo Medical Center Toledo Ohio USA
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18
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Roumiguié M, Kamat AM, Bivalacqua TJ, Lerner SP, Kassouf W, Böhle A, Brausi M, Buckley R, Persad R, Colombel M, Lamm D, Palou-Redorta J, Soloway M, Brothers K, Steinberg G, Lotan Y, Sylvester R, Alfred Witjes J, Black PC. International Bladder Cancer Group Consensus Statement on Clinical Trial Design for Patients with Bacillus Calmette-Guérin-exposed High-risk Non-muscle-invasive Bladder Cancer. Eur Urol 2022; 82:34-46. [PMID: 34955291 DOI: 10.1016/j.eururo.2021.12.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/22/2021] [Accepted: 12/03/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT A large proportion of patients with non-muscle-invasive bladder cancer (NMIBC) fall in the gap between bacillus Calmette-Guérin (BCG)-naïve and BCG-unresponsive disease. As multiple therapeutic agents move into this gray area, there is a critical need to define the disease state and establish recommendations for optimal trial design. OBJECTIVE To develop a consensus on optimal trial design for patients with BCG-exposed NMIBC, defined as high-grade recurrence after BCG treatment that does not meet the criteria for BCG-unresponsive disease. EVIDENCE ACQUISITION We conducted a literature review using the Cochrane Library, Medline, and Embase and a review of clinical trials in ClinicalTrials.gov as a basis to generate consensus recommendations for clinical trial design in BCG-exposed NMIBC. EVIDENCE SYNTHESIS BCG-exposed NMIBC encompasses BCG resistance (presence of high-grade Ta or carcinoma in situ [CIS] at 3-mo evaluation after induction BCG) and delayed relapse. Randomized controlled trials are required to compare experimental therapies to a control arm receiving additional BCG, although ongoing BCG shortages may impact our ability to follow an optimal trial design. A placebo should be used in combination with BCG if the treatment arm includes BCG plus a study drug. Trials will either need to separate patients with and without CIS into two cohorts, or stratify by the presence of CIS at the time of randomization. If two cohorts are used, the primary endpoint for CIS patients should be complete response within a predetermined time. The primary endpoint in a cohort with Ta/T1 only, or if a single combined cohort is used, should be the duration of event-free survival. Suggested efficacy thresholds and corresponding sample sizes are provided. CONCLUSIONS The International Bladder Cancer Group has developed recommendations regarding definitions, endpoints, and clinical trial design for BCG-exposed NMIBC to encourage uniformity among studies in this disease state. PATIENT SUMMARY Our consensus provides a precise definition of the disease state for bladder cancer not invading the bladder muscle and exposed to bacillus Calmette-Guérin (BCG) treatment. Clear guidance for conducting optimal clinical trials in this disease setting was established and we believe that this will promote further progress in this field.
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Affiliation(s)
- Mathieu Roumiguié
- Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada; Department of Urology, Toulouse Cancer Institute and Toulouse University Hospital, Toulouse, France
| | - Ashish M Kamat
- Department of Urology, MD Anderson Cancer Center, Houston, TX, USA
| | - Trinity J Bivalacqua
- Perelman Center for Advanced Medicine, University of Pennsylvania, Division of Urology, Department of Surgery, Philadelphia, PA.
| | - Seth P Lerner
- Scott Department of Urology, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Wassim Kassouf
- Department of Surgery (Urology), Faculty of Medicine, McGill University, Montreal, Canada
| | - Andreas Böhle
- Departments of Urology, University of Lübeck, Lübeck, Germany; HELIOS Agnes-Karll-Krankenhaus, Bad Schwartau, Germany
| | | | - Roger Buckley
- North York General Hospital, Toronto, Ontario, Canada
| | - Raj Persad
- Department of Urology, Southmead Hospital, North Bristol Hospitals Trust, Bristol, UK
| | - Marc Colombel
- Claude Bernard University, Hôpital Edouard Herriot, Lyon, France
| | - Donald Lamm
- University of Arizona and BCG Oncology, Phoenix, AZ, USA
| | - Juan Palou-Redorta
- Department of Urology, Fundació Puigvert, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Mark Soloway
- Division of Urology, Memorial Cancer Institute, Memorial Hospital, Hollywood, FL, USA
| | - Ken Brothers
- Patient Advocate, National Cancer Institute Bladder Cancer Task Force, Snowbasin, UT, USA
| | - Gary Steinberg
- Department of Urology, NYU Langone Health, New York, NY, USA
| | - Yair Lotan
- Department of Urology, UT Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Richard Sylvester
- European Association of Urology Guidelines Office, Brussels, Belgium
| | - J Alfred Witjes
- Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter C Black
- Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada.
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19
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Sun B, Bte Rahmat JN, Kim HJ, Mahendran R, Esuvaranathan K, Chiong E, Ho JS, Neoh KG, Zhang Y. Wirelessly Activated Nanotherapeutics for In Vivo Programmable Photodynamic-Chemotherapy of Orthotopic Bladder Cancer. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2200731. [PMID: 35393785 PMCID: PMC9165499 DOI: 10.1002/advs.202200731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/28/2022] [Indexed: 06/14/2023]
Abstract
Photochemical internalization (PCI) is a promising intervention using photodynamic therapy (PDT) to enhance the activity of chemotherapeutic drugs. However, current bladder cancer treatments involve high-dose chemotherapy and high-irradiance PDT which cause debilitating side effects. Moreover, low penetration of light and drugs in target tissues and cumbersome light delivery procedures hinder the clinical utility of PDT and chemotherapy combination for PCI. To circumvent these challenges, a photodynamic-chemotherapy approach is developed comprising tumor-targeting glycosylated nanocarriers, coloaded with chlorin e6 (Ce6) and gemcitabine elaidate (GemE), and a miniaturized implantable wirelessly powered light-emitting diode (LED) as a light source. The device successfully delivers four weekly light doses to the bladder while the nanocarrier promoted the specific accumulation of drugs in tumors. This approach facilitates the combination of low-irradiance PDT (1 mW cm-2 ) and low-dose chemotherapy (≈1500× lower than clinical dose) which significantly cures and controls orthotopic disease burden (90% treated vs control, 35%) in mice, demonstrating a potential new bladder cancer treatment option.
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Affiliation(s)
- Bowen Sun
- Department of Chemical and Biomolecular EngineeringCollege of Design and EngineeringNational University of SingaporeSingapore117585Singapore
| | - Juwita Norasmara Bte Rahmat
- Department of Biomedical EngineeringCollege of Design and EngineeringNational University of SingaporeSingapore117583Singapore
| | - Han Joon Kim
- Department of Electrical and Computer EngineeringCollege of Design and EngineeringNational University of SingaporeSingapore117583Singapore
| | - Ratha Mahendran
- Department of SurgeryYong Loo Lin School of MedicineNational University of SingaporeSingapore119228Singapore
| | - Kesavan Esuvaranathan
- Department of SurgeryYong Loo Lin School of MedicineNational University of SingaporeSingapore119228Singapore
- Department of UrologyNational University Health SystemSingapore119228Singapore
| | - Edmund Chiong
- Department of SurgeryYong Loo Lin School of MedicineNational University of SingaporeSingapore119228Singapore
- Department of UrologyNational University Health SystemSingapore119228Singapore
| | - John S. Ho
- Department of Electrical and Computer EngineeringCollege of Design and EngineeringNational University of SingaporeSingapore117583Singapore
- Institute for Health Innovation and TechnologyNational University of SingaporeSingapore119276Singapore
- The N.1 Institute for HealthNational University of SingaporeSingapore117456Singapore
| | - Koon Gee Neoh
- Department of Chemical and Biomolecular EngineeringCollege of Design and EngineeringNational University of SingaporeSingapore117585Singapore
| | - Yong Zhang
- Department of Biomedical EngineeringCollege of Design and EngineeringNational University of SingaporeSingapore117583Singapore
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20
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Emerging treatment options for bacillus Calmette–Guérin-unresponsive non-muscle invasive bladder cancer. Curr Opin Support Palliat Care 2022; 16:48-53. [DOI: 10.1097/spc.0000000000000587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Bhindi B, Kool R, Kulkarni GS, Siemens DR, Aprikian AG, Breau RH, Brimo F, Fairey A, French C, Hanna N, Izawa JI, Lacombe L, McPherson V, Rendon RA, Shayegan B, So AI, Zlotta AR, Black PC, Kassouf W. Canadian Urological Association guideline on the management of non-muscle-invasive bladder cancer - Abridged version. Can Urol Assoc J 2022; 15:230-239. [PMID: 35099374 DOI: 10.5489/cuaj.7487] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Bimal Bhindi
- Section of Urology, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Ronald Kool
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Girish S Kulkarni
- Division of Urology, Department of Surgery, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | | | - Armen G Aprikian
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Rodney H Breau
- Division of Urology, University of Ottawa, Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Fadi Brimo
- Department of Pathology, McGill University Health Centre, Montreal, QC, Canada
| | - Adrian Fairey
- Division of Urology, University of Alberta, Edmonton, AB, Canada
| | - Christopher French
- Division of Urology, Department of Surgery, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Nawar Hanna
- Department of Urology, Université de Montréal, Montreal, QC, Canada
| | - Jonathan I Izawa
- Department of Surgery, Division of Urology, Western University, London, ON, Canada
| | - Louis Lacombe
- Department of Surgery, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - Victor McPherson
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Ricardo A Rendon
- Department of Urology, Dalhousie University, Halifax, NS, Canada
| | - Bobby Shayegan
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Alan I So
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Alexandre R Zlotta
- Division of Urology, Department of Surgery, Sinai Health System and Department of Surgical Oncology, University Health Network, Toronto, ON, Canada
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Wassim Kassouf
- Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
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22
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Eilender BM, Katims AB, Pfail JL, Sfakianos J. Evolving Treatment in Non-muscle-Invasive Bladder Cancer. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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23
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Goldberg IP, Lichtbroun B, Singer EA, Ghodoussipour S. Pharmacologic Therapies for Non-Muscle Invasive Bladder Cancer: Current and Future Treatments. ARCHIVES OF PHARMACOLOGY AND THERAPEUTICS 2022; 4:13-22. [PMID: 36051251 PMCID: PMC9431226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Bladder cancer is the sixth most common malignancy in the United States and 70% of cases are non-muscle invasive at the time of diagnosis. Effective treatment is crucial to prevent progression, which occurs in about 30% of patients. The American Urological Association (AUA) guidelines recommend treatment of non-muscle invasive bladder cancer (NMIBC) with intravesical Bacille Calmette-Guerin (BCG) and chemotherapy. However, ongoing shortages and high rates of BCG unresponsiveness creates a major need for novel therapies. In this narrative review, we discuss the evolving landscape of therapeutic options for NMIBC. Pembrolizumab, an anti-programmed cell death (PD)-1 antibody, was the first systemic therapy to be FDA-approved for BCG-unresponsive, high-risk disease. Promising new agents under investigation include various other checkpoint inhibitors and adenovirus-based therapies including CG0070 and nadofaragene firadenovec (rAd-IFNa/Syn3). Finally, new mechanisms of drug delivery are under investigation, including delivery with the GemRIS (TAR-200) device and delivery of intravesical chemotherapy at higher temperatures. With the promise of novel therapies on the horizon, we can expect the role of urologists in the management of NMIBC to evolve and expand.
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Affiliation(s)
| | - Benjamin Lichtbroun
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Eric A. Singer
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA,Correspondence should be addressed to Saum Ghodoussipour, MD,
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24
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Agarwal PK, Sfakianos JP, Feldman A, Tagawa ST, Black PC. A 25-year perspective on advances in an understanding of the biology, evaluation, treatment and future directions/challenges of urothelial cancer. Urol Oncol 2021; 39:528-547. [PMID: 34332848 DOI: 10.1016/j.urolonc.2021.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022]
Abstract
The Urologic Oncology Journal was founded 25 years ago and we reviewed the literature since that time in the area of urothelial cancer to see the progress and pitfalls we have made over this time period. A comprehensive literature search was conducted by the authors involved who are all actively involved in research, clinical trials, and treatment for urothelial cancer and the results were summarized over the past 25 years. The field of urothelial cancer has evolved tremendously in the last 25 years with the incorporation of molecular subtyping, novel imaging, immunotherapy, and robotic surgery. However, treatments such as BCG and radical cystectomy have remained steadfast over the last 25 years. Although we have a better understanding of the biology of bladder cancer, we still have a long way from being able to cure patients with bladder cancer and eliminate morbidity from treatments. Nevertheless, considerable progress has been made since the founding of the Urologic Oncology Journal 25 years ago.
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Affiliation(s)
- Piyush K Agarwal
- Section of Urology, Department of Surgery, UChicago Medicine, Chicago, IL.
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Adam Feldman
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Scott T Tagawa
- Division of Hematology and Oncology, Departments of Medicine and Urology, Weill Cornell Medicine, New York, NY
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
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Kim HS, Seo HK. Emerging treatments for bacillus Calmette-Guérin-unresponsive non-muscle-invasive bladder cancer. Investig Clin Urol 2021; 62:361-377. [PMID: 34085791 PMCID: PMC8246016 DOI: 10.4111/icu.20200602] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
Intravesical bacillus Calmette–Guérin (BCG) immunotherapy has been the gold standard adjuvant treatment for intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC) after transurethral resection of bladder tumor (TURBT). BCG immunotherapy prevents disease recurrence and progression to muscle-invasive disease following TURBT. Although most patients initially respond well to intravesical BCG, considerable concern has been raised for patients with BCG failure who are refractory or recur in 6 months after their last BCG, which implies ‘BCG-unresponsiveness’. Based on current clinical guidelines, early radical cystectomy (RC) is recommended to treat BCG-unresponsive NMIBC. However, due to the high risk of morbidity and mortality of RC and patients' desire to preserve their own bladder, there is a critical unmet need for alternative conservative treatments as bladder-sparing strategies in BCG-unresponsive patients. Trials for effective bladder-sparing treatments are ongoing, and several novel agents have been recently tested in the NMIBC setting. The goal of this review is to introduce and summarize recently reported novel and emerging drugs and ongoing clinical trials for BCG-unresponsive NMIBC.
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Affiliation(s)
- Hyung Suk Kim
- Department of Urology, Dongguk University Ilsan Medical Center, Dongguk University School of Medicine, Goyang, Korea
| | - Ho Kyung Seo
- Department of Urology, Center for Urologic Cancer, National Cancer Center, Goyang, Korea.,Division of Tumor Immunology, Department of Cancer Biomedical Science, Research Institute, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea.
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The current landscape of salvage therapies for patients with bacillus Calmette-Guérin unresponsive nonmuscle invasive bladder cancer. Curr Opin Urol 2021; 31:178-187. [PMID: 33742981 DOI: 10.1097/mou.0000000000000863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Although radical cystectomy represents the gold standard treatment for patients with high-risk nonmuscle invasive bladder cancer (NMIBC) whose disease does not respond to bacillus Calmette-Guérin (BCG), many patients are unable or unwilling to undergo surgery. The need remains for effective bladder-preserving therapies. This review aims to describe existing treatments, contemporary research in this field and ongoing trials of salvage therapies for patients with BCG-unresponsive NMIBC. RECENT FINDINGS Intravesical chemotherapy has been utilized frequently in this setting. Emerging data on combination regimens such as intravesical gemcitabine and docetaxel and intravesical cabazitaxel, gemcitabine and cisplatin are promising; nevertheless, larger, prospective trials are needed. Meanwhile, the intravenous checkpoint inhibitor pembrolizumab was recently FDA-approved for patients BCG-unresponsive NMIBC. Encouraging clinical trial results for intravesical nadofaragene firadenovec, oportuzumab monatox and ALT-803 + BCG have been released, while data from trials of other treatment strategies, including novel chemotherapy and drug delivery, augmented BCG immunotherapy, adenoviral and gene therapy, targeted therapy, and combination systemic immunotherapy with intravesical agents, are eagerly awaited. SUMMARY Several novel salvage therapies offer promise for patients with BCG-unresponsive NMIBC. Patient selection, efficacy, safety, cost and ease of administration must be carefully considered to determine the optimal treatment approach.
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BCG-unresponsive high-grade non-muscle invasive bladder cancer: what does the practicing urologist need to know? World J Urol 2021; 39:4037-4046. [PMID: 33772322 PMCID: PMC7997797 DOI: 10.1007/s00345-021-03666-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/10/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose Bacille Calmette-Guérin (BCG) is a well-established treatment for preventing or delaying tumour recurrence following high-grade nonmuscle invasive bladder cancer (NMIBC) resection. However, many patients will experience recurrence or progression during or following BCG. This scenario has been one of the most challenging in urologic oncology for several decades since BCG implementation. Finally, significant progress has occurred lately. The aim of this review was to summarize for the practising urologist the current treatment options available in 2020 or expected to be ready for routine use in the near future for patients with high-risk NMIBC who experience BCG failure. Methods Narrative review using data through the end of 2020. Results First, the definition of BCG unresponsive disease which is critical in counseling and managing patients has finally reached a consensus. Second, some promising options other than radical cystectomy are finally available and many other should be in a near future. The options can be categorized as chemotherapy, device-assisted therapy, check-point inhibitors, new intravesical and systemic agents and sequential combinations of these newer modalities with conventional therapy. Conclusions Considering the options that are currently under scrutiny, many of which in phase III trials, clinicians should have at their disposal several new treatment options in the next five years.
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Álvarez-Maestro M, Guerrero-Ramos F, Rodríguez-Faba O, Domínguez-Escrig J, Fernández-Gómez J. Current treatments for BCG failure in non-muscle invasive bladder cancer (NMIBC). Actas Urol Esp 2021; 45:93-102. [PMID: 33012593 DOI: 10.1016/j.acuro.2020.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/22/2020] [Indexed: 12/17/2022]
Abstract
The treatment of choice for high-risk non-muscle invasive bladder cancer (NMIBC) is bacillus Calmette-Guérin (BCG). However, when this fails, the indicated treatment is radical cystectomy. In recent years, trials are being developed with various drugs to avoid this surgery in patients with BCG failure. The aim of this article is to update the treatments under study for bladder preservation in this patient population. Non-systematic review, searching PubMed with the terms "Bladder cancer", "Non-muscle invasive bladder cancer", "NMIBC", "BCG", "BCG-refractory", "Mitomycin C", "MMC", "Hyperthermia", "Electromotive Drug Administration", "EMDA". We used the search engines clinicaltrials.gov and clinicaltrialsregister.eu to find clinical trials. The only intravesical drug approved by the Food and Drug Administration (FDA) for carcinoma in situ (CIS) after failure to BCG is Valrubicin. Recently, the FDA has approved intravenous Pembrolizumab, following the publication of preliminary data from the KEYNOTE-057 study. Atezolizumab has demonstrated similar preliminary efficacy results. Only microwave-induced chemohyperthermia and EMDA-MMC (Electromotive Drug Administration) are recognized as alternatives in European guidelines. Other options under investigation are taxanes and gemcitabine, alone or in combination, recombinant viruses and device-assisted intravesical chemohyperthermia. The results of new drugs are promising, with a large number of trials underway. Knowing the mechanisms of resistance to BCG is essential to explore new therapeutic options.
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Haas CR, Caputo JM, McKiernan JM. Adjuvant Intravesical Chemotherapy. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Boorjian SA, Alemozaffar M, Konety BR, Shore ND, Gomella LG, Kamat AM, Bivalacqua TJ, Montgomery JS, Lerner SP, Busby JE, Poch M, Crispen PL, Steinberg GD, Schuckman AK, Downs TM, Svatek RS, Mashni J, Lane BR, Guzzo TJ, Bratslavsky G, Karsh LI, Woods ME, Brown G, Canter D, Luchey A, Lotan Y, Krupski T, Inman BA, Williams MB, Cookson MS, Keegan KA, Andriole GL, Sankin AI, Boyd A, O'Donnell MA, Sawutz D, Philipson R, Coll R, Narayan VM, Treasure FP, Yla-Herttuala S, Parker NR, Dinney CPN. Intravesical nadofaragene firadenovec gene therapy for BCG-unresponsive non-muscle-invasive bladder cancer: a single-arm, open-label, repeat-dose clinical trial. Lancet Oncol 2021; 22:107-117. [PMID: 33253641 PMCID: PMC7988888 DOI: 10.1016/s1470-2045(20)30540-4] [Citation(s) in RCA: 168] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/25/2020] [Accepted: 08/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND BCG is the most effective therapy for high-risk non-muscle-invasive bladder cancer. Nadofaragene firadenovec (also known as rAd-IFNa/Syn3) is a replication-deficient recombinant adenovirus that delivers human interferon alfa-2b cDNA into the bladder epithelium, and a novel intravesical therapy for BCG-unresponsive non-muscle-invasive bladder cancer. We aimed to evaluate its efficacy in patients with BCG-unresponsive non-muscle-invasive bladder cancer. METHODS In this phase 3, multicentre, open-label, repeat-dose study done in 33 centres (hospitals and clinics) in the USA, we recruited patients aged 18 years or older, with BCG-unresponsive non-muscle-invasive bladder cancer and an Eastern Cooperative Oncology Group status of 2 or less. Patients were excluded if they had upper urinary tract disease, urothelial carcinoma within the prostatic urethra, lymphovascular invasion, micropapillary disease, or hydronephrosis. Eligible patients received a single intravesical 75 mL dose of nadofaragene firadenovec (3 × 1011 viral particles per mL). Repeat dosing at months 3, 6, and 9 was done in the absence of high-grade recurrence. The primary endpoint was complete response at any time in patients with carcinoma in situ (with or without a high-grade Ta or T1 tumour). The null hypothesis specified a complete response rate of less than 27% in this cohort. Efficacy analyses were done on the per-protocol population, to include only patients strictly meeting the BCG-unresponsive definition. Safety analyses were done in all patients who received at least one dose of treatment. The study is ongoing, with a planned 4-year treatment and monitoring phase. This study is registered with ClinicalTrials.gov, NCT02773849. FINDINGS Between Sept 19, 2016, and May 24, 2019, 198 patients were assessed for eligibility. 41 patients were excluded, and 157 were enrolled and received at least one dose of the study drug. Six patients did not meet the definition of BCG-unresponsive non-muscle-invasive bladder cancer and were therefore excluded from efficacy analyses; the remaining 151 patients were included in the per-protocol efficacy analyses. 55 (53·4%) of 103 patients with carcinoma in situ (with or without a high-grade Ta or T1 tumour) had a complete response within 3 months of the first dose and this response was maintained in 25 (45·5%) of 55 patients at 12 months. Micturition urgency was the most common grade 3-4 study drug-related adverse event (two [1%] of 157 patients, both grade 3), and there were no treatment-related deaths. INTERPRETATION Intravesical nadofaragene firadenovec was efficacious, with a favourable benefit:risk ratio, in patients with BCG-unresponsive non-muscle-invasive bladder cancer. This represents a novel treatment option in a therapeutically challenging disease state. FUNDING FKD Therapies Oy.
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Affiliation(s)
| | | | | | - Neal D Shore
- Carolina Urologic Research Center, Myrtle Beach, SC, USA
| | - Leonard G Gomella
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Trinity J Bivalacqua
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Seth P Lerner
- Scott Department of Urology, Dan L Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Joseph E Busby
- Cancer Centers of the Carolinas, Greenville Hospital System, Greenville, SC, USA
| | - Michael Poch
- Department of GU Oncology, H Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Paul L Crispen
- Department of Urology, University of Florida, Gainesville, FL, USA
| | - Gary D Steinberg
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Anne K Schuckman
- USC Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Tracy M Downs
- Department of Urology, University of Wisconsin, Madison, WI, USA
| | - Robert S Svatek
- Department of Urology, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | - Brian R Lane
- Division of Urology, Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Thomas J Guzzo
- Division of Urology, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Michael E Woods
- Department of Urology, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - Adam Luchey
- West Virginia University Cancer Institute, Morgantown, WV, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tracey Krupski
- Department of Urology, University of Virginia Cancer Center, Charlottesville, VA, USA
| | - Brant A Inman
- Division of Urology, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | - Michael S Cookson
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kirk A Keegan
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gerald L Andriole
- Washington University School of Medicine in St Louis, St Louis, MO, USA
| | | | | | | | | | | | | | - Vikram M Narayan
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Seppo Yla-Herttuala
- AI Virtanen Institute University of Eastern Finland and Science Service Center and Gene Therapy Unit, Kuopio, Finland
| | - Nigel R Parker
- AI Virtanen Institute University of Eastern Finland and Science Service Center and Gene Therapy Unit, Kuopio, Finland
| | - Colin P N Dinney
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Kulkarni GS. Nadofaragene firadenovec: a new gold standard for BCG-unresponsive bladder cancer? Lancet Oncol 2021; 22:8-9. [DOI: 10.1016/s1470-2045(20)30586-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 10/22/2022]
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32
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Novel Adjuvant Therapies for Upper Tract Urothelial Carcinoma After Endoscopic Management. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Moussa M, Papatsoris AG, Dellis A, Abou Chakra M, Saad W. Novel anticancer therapy in BCG unresponsive non-muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2020; 20:965-983. [PMID: 32915676 DOI: 10.1080/14737140.2020.1822743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Many patients with non-muscle-invasive bladder cancer (NMIBC) failed intravesical BCG therapy. Currently, radical cystectomy is the recommended standard of care for those patients. There is unfortunately no effective other second-line therapy recommended. AREAS COVERED In this review, we present the topics of BCG unresponsive NMIBC; definition, prognosis, and further treatment options: immunotherapy, intravesical chemotherapy, gene therapy, and targeted individualized therapy. EXPERT OPINION There are major challenges of the management of NMIBC who failed BCG therapy as many patients refuse or are unfit for radical cystectomy. Multiple new modalities currently under investigation in ongoing clinical trials to better treat this category of patients. Immunotherapy, especially PD-1/PD-L1 inhibitors, offers exciting and potentially effective strategies for the treatment of BCG unresponsive NMIBC. As the data expands, it is sure that soon there will be established new guidelines for NMIBC.
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Affiliation(s)
- Mohamad Moussa
- Head of Urology Department, Zahraa Hospital, University Medical Center, Lebanese University , Beirut, Lebanon
| | - Athanasios G Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens , Athens, Greece
| | - Athanasios Dellis
- Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens , Athens, Greece
| | - Mohamed Abou Chakra
- Faculty of Medical Sciences, Department of Urology, Lebanese University , Beirut,Lebanon
| | - Wajih Saad
- Head of Oncology Department, Zahraa Hospital, University Medical Center, Lebanese University , Beirut, Lebanon
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Juvet T, Mari A, Lajkosz K, Wallis CJ, Kuk C, Erlich A, Krimus L, Fleshner NE, Kulkarni GS, Zlotta AR. Sequential administration of Bacillus Calmette-Guerin (BCG) and Electromotive Drug Administration (EMDA) of mitomycin C (MMC) for the treatment of high-grade nonmuscle invasive bladder cancer after BCG failure. Urol Oncol 2020; 38:850.e9-850.e15. [PMID: 32712139 DOI: 10.1016/j.urolonc.2020.06.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/08/2020] [Accepted: 06/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is a need for effective nonsurgical treatment options in patients with nonmuscle invasive bladder cancer (NMIBC) in whom Bacillus Calmette-Guerin (BCG) therapy has failed. OBJECTIVE We aimed to determine the efficacy of Electromotive Drug Administration (EMDA) of mitomycin C (MMC) with NMIBC after BCG failure. DESIGN, SETTING, AND PARTICIPANTS A retrospective review of 26 NMIBC patients in whom BCG therapy failed who received BCG/EMDA-MMC between 2013 and 2017 was performed. All but 4 patients fulfilled the FDA criteria for BCG unresponsive disease. Progression and recurrence-free survival (RFS)were calculated using Kaplan-Meier curves. Progression was defined as development of muscle invasive disease, presence of metastasis on imaging or treatment. We used FDA-defined criteria as complete response (CR) for single-arm trials of BCG-unresponsive patients. RESULTS AND LIMITATIONS Twenty-six patients were included. Initial pathology was carcinoma in situ (CIS) in 53.8% (14/26), pT1 in 34.6% (9/26), and pTa HG disease in 11.6% (3/26). Twelve of 26 patients progressed (46.2%). Following BCG/EMDA-MMC treatment, progression-free survival rates were 58.3% (95% confidence interval [CI] 41.1-82.1) at 1 year and 48.9% (95% CI 48.9) at 2 years from the date of induction of BCG/EMDA-MMC, respectively. RFS was 41.9% (95% CI 25.9-67.8) at 1 year and 27.2% (95% CI 13.6-54.4) at 2 years. CR at 6, 12, and 18 months was observed in 16 (61.5%), 11 (44.0%), and 7 patients (30.4%), respectively. Side effects included dysuria (19.2%), hematuria (19.2%), and frequency (11.5%). Three patients were admitted for side effects but managed conservatively. Four patients (15.4%) died of bladder cancer over the course of the study. CONCLUSIONS EMDA-MMC BCG represents a viable option in patients with BCG unresponsive NMIBC with close to 50% progression-free survival at 2 years. However, these patients have a high risk of death from bladder cancer (15% in our cohort at 2 years) thus warranting extremely close surveillance.
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Affiliation(s)
- Tristan Juvet
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada
| | - Andrea Mari
- Department of Urology, University of Florence, Florence, Italy
| | - Katherine Lajkosz
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada; Department of Biostatistics, University Health Network, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Christopher Jd Wallis
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada
| | - Cynthia Kuk
- Department of Surgery, Urology, Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - Annette Erlich
- Department of Surgery, Urology, Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - Lior Krimus
- University of Toronto, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Neil E Fleshner
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada
| | - Girish S Kulkarni
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada
| | - Alexandre R Zlotta
- Department of Surgical Oncology, Urology. University Health Network, Toronto, ON, Canada; Department of Surgery, Urology, Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada.
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Hurle R, Casale P, Morenghi E, Saita A, Buffi N, Lughezzani G, Colombo P, Contieri R, Frego N, Guazzoni G, Lazzeri M. Intravesical gemcitabine as bladder‐preserving treatment for BCG unresponsive non‐muscle‐invasive bladder cancer. Results from a single‐arm, open‐label study. BJUI COMPASS 2020; 1:126-132. [PMID: 35474942 PMCID: PMC8988784 DOI: 10.1002/bco2.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 12/14/2022] Open
Abstract
Background There is an unmet alternative medical therapy for BCG unresponsive patients. Objective To report efficacy of intravesical gemcitabine in NMIBC patients, who failed a previous course of BCG, or intolerant, and unwilling to undergo radical cystectomy (RC). Material and methods This is an open‐label, single‐arm study, which enrolled patients showing a failure or were intolerant to BCG and unwilling to undergo the RC. Intravesical gemcitabine was administered once a week for six consecutive weeks and once a month for 12 months. The primary outcome was DFS defined as the lack of a tumor on cystoscopy and negative urine cytology. Secondary endpoint was safety defined according a grading of side effects. OS, PFS, and DFS were described with Kaplan–Meier method at 12 and 24 months. Results and limitations Overall 36 patients were enrolled. The median follow‐up was 27 months. The DFS was 68.75% at the end of induction phase and 44.44% and 31.66% at 12 and 24 months of, respectively. The PFS was 43.75%. The OS and CSS were 77.9% (95% CI 58.78%‐88.92%) and 80.68% (95% CI 61.49%‐90.96%), respectively. There was no life threatening event or treatment‐related death (grade 4 or 5). The most common mild and moderate adverse events reported were urinary symptoms (LUTS) and fatigue (G1‐G2). Conclusion Patients who presented an unresponsive‐BCG recurrent NMIBC and unwilling to receive a RC, could benefit from intravesical gemcitabine as salvage organ‐sparing treatment.
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Affiliation(s)
- Rodolfo Hurle
- Department of Urology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
| | - Paolo Casale
- Department of Urology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
| | - Emanuela Morenghi
- Department of Medical Statistic Humanitas Clinical and Research Center - IRCCSRozzano Italy
| | - Alberto Saita
- Department of Urology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
| | - Nicolòmaria Buffi
- Department of Urology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
- Department of Medical Statistic Humanitas Clinical and Research Center - IRCCSRozzano Italy
- Department of Biomedical Sciences Humanitas University Milan Italy
| | - Giovanni Lughezzani
- Department of Urology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
- Department of Medical Statistic Humanitas Clinical and Research Center - IRCCSRozzano Italy
- Department of Biomedical Sciences Humanitas University Milan Italy
| | - Piergiuseppe Colombo
- Department of Pathology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
| | - Roberto Contieri
- Department of Urology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
| | - Nicola Frego
- Department of Urology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
| | - Giorgio Guazzoni
- Department of Urology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
- Department of Medical Statistic Humanitas Clinical and Research Center - IRCCSRozzano Italy
- Department of Biomedical Sciences Humanitas University Milan Italy
| | - Massimo Lazzeri
- Department of Urology Humanitas Clinical and Research Center - IRCCS Rozzano Italy
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Rao MY, Kang P, Tarajkowski JC, Mobley DL, Lamm DL. Salvage Hyperthermic Gemcitabine and Docetaxel Combination Chemotherapy After BCG Failure in Non-Muscle Invasive Bladder Cancer Patients. Bladder Cancer 2020. [DOI: 10.3233/blc-190245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Bacillus Calmette-Guerin (BCG) is the recommended therapy for high and intermediate risk non-muscle invasive bladder cancer (NMIBC), but treatment failure is common. While a radical cystectomy is recommended after BCG failure, some patients desire bladder preservation and others are poor surgical candidates. Salvage chemotherapy treatments may be offered to this subgroup of patients. OBJECTIVE: To assess if combination, hyperthermic Gemcitabine and Docetaxel chemotherapy (GEM/DOCE) is a safe and effective salvage option for treating NMIBC. METHODS: Sixty patients who received our GEM/DOCE protocol between 2007–2017 were identified (51 BCG failures, 9 BCG naïve). This study measured overall treatment success, defined as no recurrence, progression, cystectomy, nor death due to bladder cancer. Kaplan-Meier curves were used to ascertain probability of treatment success. The log-rank test was used to identify factors associated with treatment success. RESULTS: Sixty patients received treatment with a median follow-up of 14.9 months. All patients completed the induction course with no significant adverse effects. Overall treatment success was 83% at first surveillance, 69% at 1 year, and 55% at 2 years in the entire cohort, and 90% at first surveillance, 74% at 1 year, and 56% at 2 years in the BCG-failure patients. All-cause and bladder-cancer-specific survival were both 97.9% at 1 year, 85.9% and 94.6% respectively at 2 years. Three patients underwent cystectomy at a median of 10.2 months, two of these were secondary to recurrences. Three patients had progression of their disease. CONCLUSIONS: Hyperthermic GEM/DOCE seems to be a well-tolerated salvage regimen that demonstrates a reasonable efficacy and warrants further investigation.
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Affiliation(s)
- Mounica Y. Rao
- University of Arizona College of Medicine- Phoenix, Phoenix, AZ, USA
| | - Paul Kang
- University of Arizona College of Medicine- Phoenix, Phoenix, AZ, USA
| | | | | | - Donald L. Lamm
- University of Arizona College of Medicine- Phoenix, Phoenix, AZ, USA
- BCG Oncology, Phoenix, AZ, USA
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Kamat AM, Lerner SP, O'Donnell M, Georgieva MV, Yang M, Inman BA, Kassouf W, Boorjian SA, Tyson MD, Kulkarni GS, Chang SS, Konety BR, Svatek RS, Balar A, Witjes JA. Evidence-based Assessment of Current and Emerging Bladder-sparing Therapies for Non-muscle-invasive Bladder Cancer After Bacillus Calmette-Guerin Therapy: A Systematic Review and Meta-analysis. Eur Urol Oncol 2020; 3:318-340. [PMID: 32201133 DOI: 10.1016/j.euo.2020.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/15/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
CONTEXT Currently, there is no standard of care for patients with non-muscle-invasive bladder cancer (NMIBC) who recur despite bacillus Calmette-Guerin (BCG) therapy. Although radical cystectomy is recommended, many patients decline to undergo or are ineligible to receive it. Multiple agents are being investigated for use in this patient population. OBJECTIVE To systematically synthesize and describe the efficacy and safety of current and emerging treatments for NMIBC patients after treatment with BCG. EVIDENCE ACQUISITION A systematic literature search of MEDLINE, Embase, and the Cochrane Controlled Register of Trials (period limited to January 2007-June 2019) was performed. Abstracts and presentations from major conference proceedings were also reviewed. Randomized controlled trials were assessed using the Cochrane risk of bias tool. Data for single-arm trials were pooled using a random-effect meta-analysis with the proportions approach. Trials were grouped based on the minimum number of prior BCG courses required before enrollment and further stratified based on the proportion of patients with carcinoma in situ (CIS). EVIDENCE SYNTHESIS Thirty publications were identified with data from 23 trials for meta-analysis, of which 17 were single arm. Efficacy and safety outcomes varied widely across studies. Heterogeneity across trials was reduced in subgroup analyses. The pooled 12-mo response rates were 24% (95% confidence interval [CI]: 16-32%) for trials with two or more prior BCG courses and 36% (95% CI: 25-47%) for those with one or more prior BCG courses. In a subgroup analysis, inclusion of ≥50% of patients with CIS was associated with a lower response. CONCLUSIONS The variability in efficacy and safety outcomes highlights the need for consistent endpoint reporting and patient population definitions. With promising emerging treatments currently in development, efficacious and safe therapeutic options are urgently needed for this difficult-to-treat patient population. PATIENT SUMMARY We examined the efficacy and safety outcomes of treatments for non-muscle-invasive bladder cancer after bacillus Calmette-Guerin therapy. Outcomes varied across studies and patient populations, but emerging treatments currently in development show promising efficacy.
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Affiliation(s)
- Ashish M Kamat
- University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - J Alfred Witjes
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Abstract
PURPOSE OF REVIEW To give an overview of current options for conservative treatment of patients failing intravesical bacillus Calmette-Guerin (BCG) and to discuss emerging approaches with potential future clinical applications. RECENT FINDINGS Radical cystectomy is the standard-of-care for patients failing BCG therapy. In patients unfit or unwilling to undergo surgery, salvage therapy options could be proposed with the aim to offer local cancer control and prevent progression to muscle-invasive disease. Salvage treatments have been conducted using intravesical chemotherapy regimens, chemoradiation or chemohyperthermia. Intravesical agents such as valrubicin, gemcitabine or docetaxel showed response rates varying between 16 and 40%, whereas combination treatments of gemcitabine with docetaxel or mitomycin reported response rates in up to 50% of all patients with durable responses in about one out of three patients. For chemohyperthermia, 2-year recurrence rates between 41 and 56% have been reported. Ongoing clinical trials are evaluating chemoradiation as well as novel approaches such as systemic immunotherapy, viral gene therapy, targeted therapy or vaccination strategies with promising preliminary outcomes. SUMMARY Salvage therapeutic bladder-sparing strategies for BCG failure such as intravesical chemotherapy or chemoradiation should currently only be considered in patients unfit for or refusing surgery. Innovative concepts such as chemohyperthermia, checkpoint inhibitors, targeted therapy or viral gene therapy could lead to major changes in clinical management of BCG failures in the future.
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Li R, Sundi D, Zhang J, Kim Y, Sylvester RJ, Spiess PE, Poch MA, Sexton WJ, Black PC, McKiernan JM, Steinberg GD, Kamat AM, Gilbert SM. Systematic Review of the Therapeutic Efficacy of Bladder-preserving Treatments for Non-muscle-invasive Bladder Cancer Following Intravesical Bacillus Calmette-Guérin. Eur Urol 2020; 78:387-399. [PMID: 32143924 DOI: 10.1016/j.eururo.2020.02.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 02/14/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT There is a critical need for effective bladder-sparing therapies for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC). Owing to the current lack of effective agents that can be used as a control, the US Food and Drug Administration began to accept single-arm trials for patients with carcinoma in situ (CIS), using complete response rate (CRR) and duration of response as the primary endpoints to support marketing applications. Despite the ensuing growth of clinical trials in this space, no consensus exists on a clinically relevant benchmark for CRR. OBJECTIVE To elucidate the CRR and recurrence-free rate (RFR) using bladder-sparing agents after BCG failure in order to provide a frame of reference for future clinical trial results. EVIDENCE ACQUISITION We performed a systematic review of clinical trials utilizing bladder-sparing therapeutics for NMIBC recurring after intravesical BCG (PROSPERO CRD42019130553). The search was performed in MEDLINE, EMBASE, and Cochrane Library. Relevant studies identified from bibliography search and conference abstracts were searched to complement the systematic review. A total of 42 studies utilizing 24 treatment options and consisting of 2254 patients were included for final analysis. EVIDENCE SYNTHESIS Median CRRs in the treatment of CIS-containing tumors were 26% at 6 mo, 17% at 12 mo, and 8% at 24 mo after treatment. In comparison, median RFRs in the papillary-only studies were 67% at 6 mo, 44% at 12 mo, and 10% at 24 mo. Specifically in the BCG-unresponsive population, 6- and 12-mo CRRs in CIS-containing patients treated with Mycobacterium phlei cell wall-nucleic acid complex were 45% and 27%, respectively, and the median 6-, 12-, and 24-mo disease-free rates in the other studies were 43%, 35%, and 18%, respectively. The median progression-free rate was 91%: 95% in the CIS-containing studies and 89% in studies restricted to papillary-only recurrences. Toxicities of intravesical agents were generally mild, with very few dose limiting toxicities. CONCLUSIONS We demonstrate that, to date, bladder-sparing therapies achieved modest efficacy in patients with NMIBC after BCG. Results from the current study will serve as a frame of reference for emerging trial results in the BCG-unresponsive space. PATIENT SUMMARY In this study, we found that bladder-sparing therapies achieved modest efficacy in patients with non-muscle-invasive bladder cancer after bacillus Calmette-Guérin (BCG). These results will serve to inform future clinical trial results for salvage agents used to treat BCG-unresponsive bladder cancer.
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| | - Debasish Sundi
- Department of Urology, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Jingsong Zhang
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | | | - Philippe E Spiess
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Michael A Poch
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Wade J Sexton
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Peter C Black
- Vancouver Prostate Center, Department of Urologic Sciences, University of British Columbia, Vancouver, Canada
| | | | | | - Ashish M Kamat
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
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Daniels MJ, Barry E, Milbar N, Schoenberg M, Bivalacqua TJ, Sankin A, Kates M. An evaluation of monthly maintenance therapy among patients receiving intravesical combination gemcitabine/docetaxel for nonmuscle-invasive bladder cancer. Urol Oncol 2020; 38:40.e17-40.e24. [DOI: 10.1016/j.urolonc.2019.07.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/20/2019] [Accepted: 07/27/2019] [Indexed: 12/22/2022]
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Stromyer ML, Southerland MR, Satyal U, Sikder RK, Weader DJ, Baughman JA, Youngs WJ, Abbosh PH. Synthesis, characterization, and biological activity of a triphenylphosphonium-containing imidazolium salt against select bladder cancer cell lines. Eur J Med Chem 2020; 185:111832. [PMID: 31718944 PMCID: PMC7224591 DOI: 10.1016/j.ejmech.2019.111832] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 01/26/2023]
Abstract
Imidazolium salts have shown great promise as anticancer materials. A new imidazolium salt (TPP1), with a triphenylphosphonium substituent, has been synthesized and evaluated for in vitro and in vivo cytotoxicity against bladder cancer. TPP1 was determined to have a GI50 ranging from 200 to 250 μM over a period of 1 h and the ability to effectively inhibit bladder cancer. TPP1 induces apoptosis, and it appears to act as a direct mitochondrial toxin. TPP1 was applied intravesically to a bladder cancer mouse model based on the carcinogen N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN). Cancer selectivity of TPP1 was demonstrated, as BBN-induced tumors exhibited apoptosis but normal adjacent urothelium did not. These results suggest that TPP1 may be a promising intravesical agent for the treatment of bladder cancer.
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Affiliation(s)
- Michael L Stromyer
- Department of Chemistry, The University of Akron, 190 East Buchtel Commons, Akron, OH, 44325, USA
| | - Marie R Southerland
- Department of Chemistry, The University of Akron, 190 East Buchtel Commons, Akron, OH, 44325, USA
| | - Uttam Satyal
- Molecular Therapeutics Program, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Rahmat K Sikder
- Molecular Therapeutics Program, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - David J Weader
- Department of Chemistry, The University of Akron, 190 East Buchtel Commons, Akron, OH, 44325, USA; Molecular Therapeutics Program, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA
| | - Jessi A Baughman
- Department of Chemistry, The University of Akron, 190 East Buchtel Commons, Akron, OH, 44325, USA
| | - Wiley J Youngs
- Department of Chemistry, The University of Akron, 190 East Buchtel Commons, Akron, OH, 44325, USA.
| | - Philip H Abbosh
- Molecular Therapeutics Program, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA, 19111, USA.
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Current Clinical Trials in Non-muscle-Invasive Bladder Cancer: Heightened Need in an Era of Chronic BCG Shortage. Curr Urol Rep 2019; 20:84. [DOI: 10.1007/s11934-019-0952-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Hobbs C, Bass E, Crew J, Mostafid H. Intravesical BCG: where do we stand? Past, present and future. JOURNAL OF CLINICAL UROLOGY 2019. [DOI: 10.1177/2051415818817120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
High and intermediate risk non-muscle invasive bladder cancer poses a real challenge for treatment. Approximately 70% of bladder cancer presents as non-muscle invasive and 20–25% will progress to muscle invasive disease. Recurrences occur in up to 70% but treatment options are limited. Intravesical bacillus Calmette–Guérin is still considered the bladder sparing treatment of choice despite its well documented pitfalls. This review considers how bacillus Calmette–Guérin has become the recommended treatment, its benefits and risks and the alternative options for treatment. Level of evidence: Not applicable for this multicentre audit.
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Affiliation(s)
| | - Edward Bass
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
| | - Jeremy Crew
- Department of Urology, Churchill Hospital, UK
| | - Hugh Mostafid
- Department of Urology, Royal Surrey County NHS Foundation Trust, UK
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44
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Abstract
PURPOSE OF REVIEW To review the current literature concerning the intravesical treatment of nonmuscle invasive bladder cancer. RECENT FINDINGS Bladder cancer is a high prevalent disease. Despite the recognized efficacy of traditional intravesical therapies, the best treatment strategy still needs to be found. Improvement in bladder cancer research lead to develop new intravesical agents and drug delivery systems for nonmuscle invasive bladder cancer tumours. Moreover, the emerging knowledge of bladder cancer immune profile strongly improves and provides new available treatment strategies. SUMMARY The future of nonmuscle invasive bladder cancer therapy will be influenced by the development of immunotherapy and new technologies for device-assisted treatment. Moreover, nanotechnology and delivery systems present promising results.
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Joice GA, Bivalacqua TJ, Kates M. Optimizing pharmacokinetics of intravesical chemotherapy for bladder cancer. Nat Rev Urol 2019; 16:599-612. [PMID: 31434998 DOI: 10.1038/s41585-019-0220-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2019] [Indexed: 12/20/2022]
Abstract
Non-muscle-invasive bladder cancer (NMIBC) remains one of the most common malignancies and is associated with considerable treatment costs. Patients with intermediate-risk or high-risk disease can be treated with intravesical BCG, but many of these patients will experience tumour recurrence, despite adequate treatment. Standard of care in these patients is radical cystectomy with urinary diversion, but this approach is associated with considerable morbidity and lifestyle modification. As an alternative, perioperative intravesical chemotherapy is recommended for low-risk papillary NMIBC, and induction intravesical chemotherapy is an option for patients with intermediate-risk NMIBC and BCG-unresponsive NMIBC. However, poor pharmaceutical absorption and drug washout during normal voiding can limit sustained drug concentrations in the urothelium, which reduces efficacy, and small-molecule chemotherapeutic agents can be absorbed through the urothelium into the bloodstream, leading to systemic adverse effects. Several novel drug delivery methods - including hyperthermia, mechanical sustained released devices and nanoparticle drug conjugation - have been developed to overcome these limitations. These novel methods have the potential to be combined with established chemotherapeutic agents to change the paradigm of NMIBC treatment.
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Affiliation(s)
- Gregory A Joice
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Max Kates
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Tse J, Singla N, Ghandour R, Lotan Y, Margulis V. Current advances in BCG-unresponsive non-muscle invasive bladder cancer. Expert Opin Investig Drugs 2019; 28:757-770. [PMID: 31412742 DOI: 10.1080/13543784.2019.1655730] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: The current first line therapy for high grade (HG) non-muscle invasive bladder cancer (NMIBC) is intravesical Bacillus Calmette-Guerin (BCG). Patients who recur or progress despite BCG are recommended to undergo radical cystectomy or participate in clinical trials. There is an urgent need for alternative therapies in the BCG-unresponsive NMIBC realm. Areas covered: We queried clinicaltrials.gov and pubmed.gov for current and recently completed early clinical trials pertaining to investigational agents used for the treatment of BCG-unresponsive NMIBC. These included intravesical chemotherapy, immunotherapy, vaccines, gene therapy, viruses, and agents used with novel drug delivery methods. In this article, we discuss the treatment guidelines for non-muscle invasive bladder cancer and therapeutic approaches under investigation in clinical trials. Expert opinion: The FDA is currently allowing single-arm studies as a pathway for approval in BCG-refractory patients with CIS. Although many agents are currently undergoing testing, none have been approved since Valrubicin. Hopefully, we will identify therapies sufficiently effective and durable to achieve FDA approval. Other considerations in this realm include the use of biomarkers in NMIBC to identify patients who will most likely respond to specific interventions. In addition, as systemic agents such as checkpoint inhibitors, are studied further, a multidisciplinary approach may be needed to treat this subset of patients.
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Affiliation(s)
- Jennifer Tse
- Department of Urology, University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Rashed Ghandour
- Department of Urology, University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center , Dallas , TX , USA
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Jamil ML, Deebajah M, Sood A, Robinson K, Rao K, Sana S, Alanee S. Protocol for phase I study of pembrolizumab in combination with Bacillus Calmette-Guérin for patients with high-risk non-muscle invasive bladder cancer. BMJ Open 2019; 9:e028287. [PMID: 31320352 PMCID: PMC6661574 DOI: 10.1136/bmjopen-2018-028287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION The initial treatment for high-risk non-muscle invasive bladder cancer (NMIBC) is endoscopic resection of the tumour followed by BCG therapy. In those who develop recurrence, the standard treatment is radical cystectomy. Despite the advancement in surgical technique and postoperative care, the degree of morbidity associated with radical cystectomy remains high, therefore less invasive treatment modalities are desirable. Therapies targeting the programmed death (PD) pathway have shown promise in urothelial carcinoma. We undertook the current study to determine the safety and efficacy of administering pembrolizumab (a monoclonal antibody targeting the interaction between PD-1 and its ligand) in combination with BCG in high-risk NMIBC. METHODS This is a single-centre phase I safety and efficacy study of pembrolizumab used in combination with intravesicular BCG treatment for subjects with pathologically documented high-risk NMIBC despite having received two courses of induction therapy or BCG treatment followed by maintenance BCG. Fifteen subjects will be enrolled, patients will receive treatment with 200 mg of pembrolizumab every 21 days, starting 2 weeks from the initial endoscopic resection and continuing for 6 weeks after the final dose of BCG. The primary objective is to determine the safety of administering pembrolizumab at a fixed dose of 200 mg every 3 weeks in conjunction with intravesicular BCG treatment in patients with high-risk NMIBC who have failed previous treatment. Secondary objectives are to determine the 19 weeks and the 3, 12 and 24 months post-treatment completion complete response rate with combined pembrolizumab and intravesicular BCG therapy in the aforementioned patients. ETHICS AND DISSEMINATION The study has been approved by the Institutional Review Board of the Henry Ford Hospital. The results of this study will be published in a peer-reviewed journal and presented at a scientific conference. TRIAL REGISTRATION NUMBER NCT02324582.
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Affiliation(s)
- Marcus L Jamil
- Henry Ford Hospital, Vattikuti Urology Institute Henry Ford Hospital, Detroit, Michigan, USA
| | - Mustafa Deebajah
- Henry Ford Hospital, Vattikuti Urology Institute Henry Ford Hospital, Detroit, Michigan, USA
| | - Akshay Sood
- Henry Ford Hospital, Vattikuti Urology Institute, Detroit, Michigan, USA
| | - Kathy Robinson
- Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Krishna Rao
- Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Sherjeel Sana
- Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Shaheen Alanee
- Henry Ford Hospital, Vattikuti Urology Institute, Detroit, Michigan, USA
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Phase I neoadjuvant study of intravesical recombinant fowlpox-GM-CSF (rF-GM-CSF) or fowlpox-TRICOM (rF-TRICOM) in patients with bladder carcinoma. Cancer Gene Ther 2019; 27:438-447. [PMID: 31222182 PMCID: PMC6923616 DOI: 10.1038/s41417-019-0112-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 01/18/2023]
Abstract
Intravesical BCG is a highly effective treatment for high-grade nonmuscle invasive bladder cancer and carcinoma in situ (CIS); however, for patients who are either resistant or become unresponsive to BCG therapy there is a need for alternative treatment approaches. This study examined the safety and feasibility of intravesically administered recombinant fowlpox virus encoding GM-CSF (Arm A) or TRICOM (Arm B); and the local and systemic immunologic responses generated to the vector(s). Twenty bladder cancer patients scheduled for cystectomy as their standard of care received preoperatively four weekly doses of intravesical recombinant fowlpox. Treatment was well tolerated, however, three patients experienced transient elevations of liver transaminases, with one rising to the level of a DLT. Cystectomy derived tumor and normal bladder mucosa demonstrated mRNA for the virally encoded LacZ gene supporting effective infection/transfection. Detected serum antibody to the LacZ encoding β-galactosidase indicated successful expression of vector-encoding gene products and the ability to immunize via the bladder site. H&E and IHC using a panel of immune cell specific antigens demonstrated immune cell infiltration of the bladder wall. These findings demonstrate good safety profile, successful infection/transfection, ability to generate systemic immune response, and local recruitment of immune cell populations with intravesical administration of fowlpox-based constructs encoding for GM-CSF(rF-GM-CSF) or TRICOM (rF-TRICOM), and support further evaluation of this treatment modality for bladder cancer.
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Ourfali S, Ohannessian R, Fassi-Fehri H, Pages A, Badet L, Colombel M. Recurrence Rate and Cost Consequence of the Shortage of Bacillus Calmette-Guérin Connaught Strain for Bladder Cancer Patients. Eur Urol Focus 2019; 7:111-116. [PMID: 31005491 DOI: 10.1016/j.euf.2019.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/10/2019] [Accepted: 04/04/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Between 2013 and 2016, global production of bacillus Calmette-Guérin (BCG) was dramatically reduced due to the collapse of the factory producing BCG Connaught. OBJECTIVE To evaluate the clinical and economic impact of BCG shortage on a cohort of non-muscle-invasive bladder cancer (NMIBC) patients treated during the period of restricted supply. DESIGN, SETTING AND PARTICIPANTS This retrospective, before and after, cost-consequence study included patients with intermediate- and high-risk NMIBC. Those resected between November 2011 and September 2013 (control group) were compared with those resected between October 2013 and December 2016 (study group). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was the rate of tumor recurrence from 30 d after transurethral resection to the end of follow-up at 24 mo; the secondary endpoints included the average cost of primary treatment, average cost of treatment of recurrence, and excess cost due to BCG shortage per patient. RESULTS AND LIMITATIONS A total of 402 patients were included: 191 in the control group and 211 in the study group. The rate of recurrence at 24 mo was significantly higher in the study group than in the control group (46.9% vs 16.2%; relative risk: 0.7, 95% confidence interval [0.60; 0.82]; p < 0.001). The increased cost due to the decrease in BCG production was estimated to be €783 per patient with a new diagnosis of NMIBC during the period of restricted supply. This is a retrospective analysis at the level of our unit. A more precise evaluation would require a study of a larger cohort of patients. CONCLUSIONS The shortage of BCG between October 2013 and December 2016 had a significant medical and economic impact; there was an increased rate of bladder cancer recurrence, and the total cost of care for intermediate- and high-risk NMIBC was higher. PATIENT SUMMARY In this report, we analyzed the medical and economic impact of bacillus Calmette-Guérin (BCG) shortage that occurred between 2013 and 2016. We found a significant increase of bladder cancer recurrence and progression, and an increase in the number of patients who had to be treated by cystectomy. BCG shortage also had a significant impact on the total cost. Since there are no alternatives to BCG for high-risk non-muscle-invasive bladder cancer patients, BCG production has to be maintained by any means.
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Affiliation(s)
- Said Ourfali
- Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot, Université Lyon Claude Bernard, Lyon, France; Hôpital Edouard Herriot, Hospices Civils de Lyon et Université Claude Bernard, Lyon, France
| | - Robin Ohannessian
- Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot, Université Lyon Claude Bernard, Lyon, France; Univ. Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Hakim Fassi-Fehri
- Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot, Université Lyon Claude Bernard, Lyon, France; Hôpital Edouard Herriot, Hospices Civils de Lyon et Université Claude Bernard, Lyon, France
| | - Alfreda Pages
- Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot, Université Lyon Claude Bernard, Lyon, France; Hôpital Edouard Herriot, Hospices Civils de Lyon et Université Claude Bernard, Lyon, France
| | - Lionel Badet
- Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot, Université Lyon Claude Bernard, Lyon, France; Hôpital Edouard Herriot, Hospices Civils de Lyon et Université Claude Bernard, Lyon, France
| | - Marc Colombel
- Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot, Université Lyon Claude Bernard, Lyon, France; Hôpital Edouard Herriot, Hospices Civils de Lyon et Université Claude Bernard, Lyon, France.
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Moschini M, Zamboni S, Mattei A, Amparore D, Fiori C, De Dominicis C, Esperto F. Bacillus Calmette-Guérin unresponsiveness in non-muscle-invasive bladder cancer patients: what the urologists should know. MINERVA UROL NEFROL 2019; 71:17-30. [DOI: 10.23736/s0393-2249.18.03309-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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