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Benjamin DJ, Mita AC. FGFR-Altered Urothelial Carcinoma: Resistance Mechanisms and Therapeutic Strategies. Target Oncol 2025; 20:1-11. [PMID: 39690380 DOI: 10.1007/s11523-024-01119-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2024] [Indexed: 12/19/2024]
Abstract
Fibroblast growth factor receptor (FGFR) 2/3 alterations have been implicated in tumorigenesis in several malignancies, including urothelial carcinoma. Several FGFR inhibitors have been studied or are in development, and erdafitinib is the sole inhibitor to achieve regulatory approval. Given the rapidly evolving treatment landscape for advanced urothelial carcinoma, including regulatory approvals and withdrawals, determining the most appropriate treatment strategies and sequencing for FGFR-altered urothelial carcinoma is becoming increasing critical. However, the clinical efficacy of FGFR inhibitors is limited by acquired resistance similar to that seen with other tyrosine kinase inhibitors. Additional challenges to the clinical use of FGFR inhibitors include treatment-related adverse events and the financial costs associated with treatment. In this review, we describe known mechanisms of FGFR inhibitor resistance, including gatekeeper mutations, domain mutations, and the development of new mutations. In addition, we discuss management strategies, including ongoing clinical trials evaluating FGFR inhibitors, antibody-drug conjugates, and combination therapies with immune checkpoint inhibitors that may provide additional treatment options for localized and metastatic urothelial carcinoma.
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Affiliation(s)
- David J Benjamin
- Hoag Family Cancer Institute, 1 Hoag Drive, Building 41, Newport Beach, CA, 92663, USA.
| | - Alain C Mita
- Hoag Family Cancer Institute, 1 Hoag Drive, Building 41, Newport Beach, CA, 92663, USA
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2
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Matsubara N, Miura Y, Nishiyama H, Taoka R, Kojima T, Shimizu N, Hwang J, Ote T, Oyama R, Toyoizumi K, Mukhopadhyay S, Triantos S, Deprince K, Loriot Y. Phase 3 THOR Japanese subgroup analysis: erdafitinib in advanced or metastatic urothelial cancer and fibroblast growth factor receptor alterations. Int J Clin Oncol 2024; 29:1516-1527. [PMID: 39017806 PMCID: PMC11420312 DOI: 10.1007/s10147-024-02583-3] [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: 05/22/2024] [Accepted: 07/02/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND In the THOR trial (NCT03390504) Cohort 1, erdafitinib demonstrated significantly prolonged overall survival (OS) (median 12.1 versus 7.8 months) and reduced risk of death by 36% (hazard ratio 0.64, P = 0.005) compared with chemotherapy in metastatic urothelial carcinoma (mUC) patients with FGFR alterations who progressed after ≥ 1 prior treatments, including anti-PD-(L)1. There have been no reports of the Japanese subgroup results yet. METHODS THOR Cohort 1 randomized patients to erdafitinib once daily or docetaxel/vinflunine once every 3 weeks. Primary endpoint was OS. Secondary endpoints included progression-free survival (PFS) and objective response rate (ORR). No specific statistical power was set for this Japanese subgroup analysis. RESULTS Of 266 patients randomized, 27 (14 erdafitinib; 13 chemotherapy) were Japanese. Baseline characteristics were generally similar between treatments and to the overall population, except for more males, lower body weight, and more upper tract primary tumors among Japanese patients. Compared with chemotherapy, erdafitinib showed improved OS (median 25.4 versus 12.4 months), PFS (median 8.4 versus 2.9 months) and ORR (57.1% versus 15.4%). Any grade treatment-related adverse events (AEs) occurred in all patients from both arms but Grade 3/4 AEs and AEs leading to discontinuation were lower in the erdafitinib arm. No new safety signals were observed in the Japanese subgroup. CONCLUSION In the Japanese subgroup, erdafitinib showed improved survival and response compared to chemotherapy, with no new safety concerns. These results support erdafitinib as a treatment option for Japanese mUC patients with FGFR alterations, and early FGFR testing after diagnosis of mUC should be considered.
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Affiliation(s)
- Nobuaki Matsubara
- Department of Medical Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Yuji Miura
- Department of Medical Oncology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Hiroyuki Nishiyama
- Department of Urology, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Rikiya Taoka
- Department of Urology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Takahiro Kojima
- Department of Urology, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Nobuaki Shimizu
- Department of Urology, Gunma Prefectural Cancer Center, 3-39-22 Showa-machi, Maebashi, Gunma, 371-8511, Japan
| | - Jason Hwang
- Department of Medical Affairs, Janssen Pharmaceutical K.K, 5-2-3 Nishikanda, Chiyoda-ku, Tokyo, 101-0065, Japan
| | - Tatsuya Ote
- Oncology Clinical Development Department, Clinical Science Division, Research and Development, Janssen Pharmaceutical K.K, 5-2-3 Nishikanda, Chiyoda-ku, Tokyo, 101-0065, Japan
| | - Ryo Oyama
- Research and Development, Janssen Pharmaceutical K.K, 5-2-3 Nishikanda, Chiyoda-ku, Tokyo, 101-0065, Japan
| | - Kiichiro Toyoizumi
- Statistics and Decision Sciences, Research and Development, Janssen Pharmaceutical K. K, 5-2-3 Nishikanda, Chiyoda-ku, Tokyo, 101-0065, Japan
| | - Sutapa Mukhopadhyay
- Janssen Research and Development, 920 US Highway 202 S, Raritan, NJ, 08807, USA
| | - Spyros Triantos
- Janssen Research and Development, 1400 McKean Road, Spring House, PA, 19477, USA
| | - Kris Deprince
- Janssen Research and Development, Turnhoutseweg 30, 2340, Beerse Anterwerpen, Belgium
| | - Yohann Loriot
- Department of Cancer Medicine, INSERM U981, Gustave Roussy, Universite Paris-Saclay, 94800, Villejuif, France
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Juan Ramon A, Parmar C, Carrasco-Zevallos OM, Csiszer C, Yip SSF, Raciti P, Stone NL, Triantos S, Quiroz MM, Crowley P, Batavia AS, Greshock J, Mansi T, Standish KA. Development and deployment of a histopathology-based deep learning algorithm for patient prescreening in a clinical trial. Nat Commun 2024; 15:4690. [PMID: 38824132 PMCID: PMC11144215 DOI: 10.1038/s41467-024-49153-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/24/2024] [Indexed: 06/03/2024] Open
Abstract
Accurate identification of genetic alterations in tumors, such as Fibroblast Growth Factor Receptor, is crucial for treating with targeted therapies; however, molecular testing can delay patient care due to the time and tissue required. Successful development, validation, and deployment of an AI-based, biomarker-detection algorithm could reduce screening cost and accelerate patient recruitment. Here, we develop a deep-learning algorithm using >3000 H&E-stained whole slide images from patients with advanced urothelial cancers, optimized for high sensitivity to avoid ruling out trial-eligible patients. The algorithm is validated on a dataset of 350 patients, achieving an area under the curve of 0.75, specificity of 31.8% at 88.7% sensitivity, and projected 28.7% reduction in molecular testing. We successfully deploy the system in a non-interventional study comprising 89 global study clinical sites and demonstrate its potential to prioritize/deprioritize molecular testing resources and provide substantial cost savings in the drug development and clinical settings.
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Affiliation(s)
- Albert Juan Ramon
- Janssen R&D, LLC, a Johnson & Johnson Company. Data Science and Digital Health, San Diego, CA, USA.
| | - Chaitanya Parmar
- Janssen R&D, LLC, a Johnson & Johnson Company. Data Science and Digital Health, San Diego, CA, USA
| | | | - Carlos Csiszer
- Janssen R&D, LLC, a Johnson & Johnson Company. Data Science and Digital Health, Titusville, NJ, USA
| | - Stephen S F Yip
- Janssen R&D, LLC, a Johnson & Johnson Company. Data Science and Digital Health, Cambridge, MA, USA
| | - Patricia Raciti
- Janssen R&D, LLC, a Johnson & Johnson Company. Oncology, Spring House, PA, USA
| | - Nicole L Stone
- Janssen R&D, LLC, a Johnson & Johnson Company. Oncology, Spring House, PA, USA
| | - Spyros Triantos
- Janssen R&D, LLC, a Johnson & Johnson Company. Oncology, Spring House, PA, USA
| | - Michelle M Quiroz
- Janssen R&D, LLC, a Johnson & Johnson Company. Oncology, Spring House, PA, USA
| | - Patrick Crowley
- Janssen R&D, LLC, a Johnson & Johnson Company. Global Development, High Wycombe, UK
| | - Ashita S Batavia
- Janssen R&D, LLC, a Johnson & Johnson Company. Data Science and Digital Health, Titusville, NJ, USA
| | - Joel Greshock
- Janssen R&D, LLC, a Johnson & Johnson Company. Data Science and Digital Health, Spring House, PA, USA
| | - Tommaso Mansi
- Janssen R&D, LLC, a Johnson & Johnson Company. Data Science and Digital Health, Titusville, NJ, USA
| | - Kristopher A Standish
- Janssen R&D, LLC, a Johnson & Johnson Company. Data Science and Digital Health, San Diego, CA, USA
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4
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Eturi A, Bhasin A, Zarrabi KK, Tester WJ. Predictive and Prognostic Biomarkers and Tumor Antigens for Targeted Therapy in Urothelial Carcinoma. Molecules 2024; 29:1896. [PMID: 38675715 PMCID: PMC11054340 DOI: 10.3390/molecules29081896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/01/2024] [Accepted: 04/19/2024] [Indexed: 04/28/2024] Open
Abstract
Urothelial carcinoma (UC) is the fourth most prevalent cancer amongst males worldwide. While patients with non-muscle-invasive disease have a favorable prognosis, 25% of UC patients present with locally advanced disease which is associated with a 10-15% 5-year survival rate and poor overall prognosis. Muscle-invasive bladder cancer (MIBC) is associated with about 50% 5 year survival when treated by radical cystectomy or trimodality therapy; stage IV disease is associated with 10-15% 5 year survival. Current therapeutic modalities for MIBC include neoadjuvant chemotherapy, surgery and/or chemoradiation, although patients with relapsed or refractory disease have a poor prognosis. However, the rapid success of immuno-oncology in various hematologic and solid malignancies offers new targets with tremendous therapeutic potential in UC. Historically, there were no predictive biomarkers to guide the clinical management and treatment of UC, and biomarker development was an unmet need. However, recent and ongoing clinical trials have identified several promising tumor biomarkers that have the potential to serve as predictive or prognostic tools in UC. This review provides a comprehensive summary of emerging biomarkers and molecular tumor targets including programmed death ligand 1 (PD-L1), epidermal growth factor receptor (EGFR), human epidermal growth factor receptor 2 (HER2), fibroblast growth factor receptor (FGFR), DNA damage response and repair (DDR) mutations, poly (ADP-ribose) polymerase (PARP) expression and circulating tumor DNA (ctDNA), as well as their clinical utility in UC. We also evaluate recent advancements in precision oncology in UC, while illustrating limiting factors and challenges related to the clinical application of these biomarkers in clinical practice.
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Affiliation(s)
- Aditya Eturi
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA; (K.K.Z.); (W.J.T.)
| | - Amman Bhasin
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Kevin K. Zarrabi
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA; (K.K.Z.); (W.J.T.)
| | - William J. Tester
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA; (K.K.Z.); (W.J.T.)
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Guercio BJ, Sarfaty M, Teo MY, Ratna N, Duzgol C, Funt SA, Lee CH, Aggen DH, Regazzi AM, Chen Z, Lattanzi M, Al-Ahmadie HA, Brannon AR, Shah R, Chu C, Lenis AT, Pietzak E, Bochner BH, Berger MF, Solit DB, Rosenberg JE, Bajorin DF, Iyer G. Clinical and Genomic Landscape of FGFR3-Altered Urothelial Carcinoma and Treatment Outcomes with Erdafitinib: A Real-World Experience. Clin Cancer Res 2023; 29:4586-4595. [PMID: 37682528 PMCID: PMC11233068 DOI: 10.1158/1078-0432.ccr-23-1283] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/02/2023] [Accepted: 09/06/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE Erdafitinib is the only FDA-approved targeted therapy for FGFR2/3-altered metastatic urothelial cancer. We characterized the genetic landscape of FGFR-altered urothelial carcinoma and real-world clinical outcomes with erdafitinib, including on-treatment genomic evolution. EXPERIMENTAL DESIGN Prospectively collected clinical data were integrated with institutional genomic data to define the landscape of FGFR2/3-altered urothelial carcinoma. To identify mechanisms of erdafitinib resistance, a subset of patients underwent prospective cell-free (cf) DNA assessment. RESULTS FGFR3 alterations predictive of erdafitinib sensitivity were identified in 39% (199/504) of patients with non-muscle invasive, 14% (75/526) with muscle-invasive, 43% (81/187) with localized upper tract, and 26% (59/228) with metastatic specimens. One patient had a potentially sensitizing FGFR2 fusion. Among 27 FGFR3-altered cases with a primary tumor and metachronous metastasis, 7 paired specimens (26%) displayed discordant FGFR3 status. Erdafitinib achieved a response rate of 40% but median progression-free and overall survival of only 2.8 and 6.6 months, respectively (n = 32). Dose reductions (38%, 12/32) and interruptions (50%, 16/32) were common. Putative resistance mutations detected in cfDNA involved TP53 (n = 5), AKT1 (n = 1), and second-site FGFR3 mutations (n = 2). CONCLUSIONS FGFR3 mutations are common in urothelial carcinoma, whereas FGFR2 alterations are rare. Discordance of FGFR3 mutational status between primary and metastatic tumors occurs frequently and raises concern over sequencing archival primary tumors to guide patient selection for erdafitinib therapy. Erdafitinib responses were typically brief and dosing was limited by toxicity. FGFR3, AKT1, and TP53 mutations detected in cfDNA represent putative mechanisms of acquired erdafitinib resistance.
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Affiliation(s)
- Brendan J Guercio
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Michal Sarfaty
- Institute of Oncology, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Min Yuen Teo
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Neha Ratna
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cihan Duzgol
- Commonwealth Radiology Associates, Andover, Massachusetts
| | - Samuel A Funt
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Chung-Han Lee
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - David H Aggen
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Ashley M Regazzi
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ziyu Chen
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Hikmat A Al-Ahmadie
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - A Rose Brannon
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ronak Shah
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carissa Chu
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew T Lenis
- Department of Urology, Columbia University Irving Medical Center, New York, New York
| | - Eugene Pietzak
- Weill Cornell Medical College, New York, New York
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bernard H Bochner
- Weill Cornell Medical College, New York, New York
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael F Berger
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Solit
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan E Rosenberg
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Dean F Bajorin
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Gopa Iyer
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
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Santini D, Banna GL, Buti S, Isella L, Stellato M, Roberto M, Iacovelli R. Navigating the Rapidly Evolving Advanced Urothelial Carcinoma Treatment Landscape: Insights from Italian Experts. Curr Oncol Rep 2023; 25:1345-1362. [PMID: 37855848 PMCID: PMC10640402 DOI: 10.1007/s11912-023-01461-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE OF REVIEW To discuss recent advances in the treatment of advanced urothelial carcinoma (UC) and how best to incorporate new therapies into clinical practice. RECENT FINDINGS There have been several recent practice-changing phase 2 and 3 trials of immune checkpoint inhibitors (ICIs), antibody-drug conjugates (ADCs), and targeted agents in advanced UC. Based on data from these trials, ICIs can be used as first-line maintenance therapy in patients who do not progress on platinum-based chemotherapy, second-line therapy for those with progression, and first-line therapy in cisplatin-ineligible patients with PD-L1 expression; ADCs and targeted agents provide later-line treatment options. Despite substantial progress in the treatment of advanced UC, there are still many uncertainties, including the optimal treatment sequence for novel agents, and reliable predictive biomarkers to aid in treatment selection. There is also an unmet need for effective treatment options in patients unfit for any platinum-based chemotherapy.
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Affiliation(s)
- Daniele Santini
- Medical Oncology A, University of Rome, Policlinico Umberto I, "La Sapienza, Rome, Italy
| | - Giuseppe Luigi Banna
- Portsmouth Hospitals University NHS Trust, Portsmouth, PO6 3LY, UK
- Faculty of Science and Health, School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, PO1 2UP, UK
| | - Sebastiano Buti
- Department of Medicine and Surgery, University of Parma, Viale A. Gramsci 14, 43126, Parma, Italy.
- Oncology Unit, University Hospital of Parma, Viale A. Gramsci 14, 43126, Parma, Italy.
| | - Luca Isella
- Department of Medicine and Surgery, University of Parma, Viale A. Gramsci 14, 43126, Parma, Italy
| | - Marco Stellato
- Medical Oncology Department, Fondazione IRCCS National Cancer Institute, Milan, Italy
| | - Michela Roberto
- UOC Oncology A, Department of Radiological, Oncological and Anatomo-Pathological Science, Policlinico Umberto I, "La Sapienza" University of Rome, Rome, Italy
| | - Roberto Iacovelli
- UOC Medical Oncology, Comprehensive Cancer Center, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
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