Gemcitabine Plus Vinorelbine Chemotherapy in Patients with Advanced Bladder Carcinoma Who Are Medically Unsuitable for or Who Have Failed Cisplatin-Based Chemotherapy

The continuing role of chemotherapy in the management of advanced urothelial cancer

Despite intense drug development in the last decade in metastatic urothelial carcinoma and the incorporation of novel compounds to the treatment armamentarium, chemotherapy remains a key treatment strategy for this disease. Platinum-based combinations are still the backbone of first-line therapy in most cases. The role of chemotherapy in the second line has been more ill-defined due to the complexity of this setting, where patient selection remains critical. Nevertheless, two regimens, one in monotherapy (i.e. vinflunine) and one in combination with antiangiogenics (i.e. docetaxel + ramucirumab) have shown efficacy. Immunotherapy through checkpoint inhibition has revealed remarkably durable benefit in a small proportion of patients in the first and second line and is currently the preferred partner for combinations with chemotherapy. Difficult populations such as patients with liver metastases or those progressing to checkpoint inhibition represent a medical challenge and selective ways of delivering cytotoxics, like the antibody-drug conjugates, might represent a valid alternative. This article reviews the current role of chemotherapy in the management of advanced urothelial carcinoma and the ongoing and coming studies involving this treatment strategy.

Gemcitabine plus split-dose cisplatin could be a promising alternative to gemcitabine plus carboplatin for cisplatin-unfit patients with advanced urothelial carcinoma

PURPOSE

Cisplatin-based chemotherapies are standard treatment regimens of advanced urothelial cell carcinoma. But a significant proportion of patients are unsuitable for cisplatin due to impaired renal function. Carboplatin-based regimens such as gemcitabine and carboplatin regimen (GCb) were applied due to less nephrotoxicity and side effects in these patients. However, it is known that clinical outcome of carboplatin-based regimens was unsatisfactory compared to cisplatin-based regimens. We compared the nephrotoxicity and response to treatment between GCb and gemcitabine plus split-dose cisplatin regimen (GC-S).

METHODS

GC-S consists of cisplatin 35 mg/m(2) given on day 1, 2 and gemcitabine 1000 mg/m(2) on day 1, 8 every 3 weeks. GCb consists of carboplatin (AUC 4.5) on day 1 and gemcitabine 1000 mg/m(2) on day 1, 8 every 3 weeks. Patient demographics, serum creatinine and calculated GFR, adverse events, and radiologic response were retrospectively reviewed.

RESULTS

Forty-four patients with advanced urothelial carcinoma treated with GCb (n = 22) or GC-S (n = 22) in our institution. There was no difference at deterioration of serum creatinine or GFR between GCb and GC-S (p = 0.442, p = 0.345). For patients who had GFR < 60 mL/min/1.73 m(2) subgroup, similar results were produced (p = 0.292, p = 0.186). In addition, GC-S (68.4 %) showed improved response compared to GCb (31.6 %) (p = 0.023). Both treatments were well tolerated, and there were no unexpected serious adverse events.

CONCLUSIONS

Based on preserved renal function, favorable response, and tolerability, GC-S could be a promising alternative to GCb for cisplatin-unfit patients with advanced urothelial carcinoma.

First-line treatment of metastatic disease: cisplatin-ineligible patients

More than 50% of patients with advanced urothelial carcinoma are not eligible for the standard treatment with cisplatin-based chemotherapy. In general, cisplatin-ineligible patients with metastatic urothelial cancer experience poor outcomes with standard treatment, although substantial heterogeneity exists. Baseline variables associated with poor prognosis include borderline performance status, presence of visceral metastases, liver metastases, and low hemoglobin. Although no standard treatment has been defined for cisplatin-ineligible patients, recommendations regarding carboplatin-based combination chemotherapy versus single-agent chemotherapy versus best supportive care are typically based on performance status and renal function. The clinical development of novel agents is of considerable interest.

Systemic therapy for bladder cancer - a medical oncologist's perspective

Advanced bladder cancer, both muscle-invasive localized disease and metastatic disease, is managed with systemic chemotherapy. Cisplatin-based multi-agent chemotherapy remains the cornerstone for systemic therapy. MVAC (methotrexate-vinblastine-doxorubicin-cisplatin) has been most rigorously studied, both neoadjuvantly and for palliation of metastatic disease. For metastatic disease, cisplatin-gemcitabine (GC) has compared favorably to MVAC due to improved tolerability with similar efficacy. GC has been adopted as standard therapy. Neoadjuvant chemotherapy for muscle-invasive bladder cancer improves survival among those patients eligible to receive cisplatin. Adjuvant chemotherapy is difficult to administer effectively given morbidity of radical cystectomy, and studies have shown mixed results about its benefit. Non-cisplatin regimens have been investigated but remain experimental and reserved for those not candidates for cisplatin in the metastatic setting. While multiple agents have been studied after metastatic disease progression after cisplatin-based therapy, there remain no FDA-approved therapies for the second line. Future trials with anti-VEGF therapy and immunotherapy are actively being investigated. This review examines the systemic therapy available to oncologists with current evidence and future directions.

Management of muscle-invasive bladder cancer in the elderly

Bladder cancer is rare in patients below the age of 50 years, and most patients are in their 60s and 70s. Radical cystectomy is the preferred approach for patients with localized disease in most European countries and the USA, and evidence is growing in favor of neoadjuvant, platinum-based chemotherapy for patients at high risk of local and systemic relapse. Transurethral resection (TUR) followed by radiotherapy with or without concomitant chemotherapy appears to be a reasonable alternative, particularly in the UK and Canada. However, the elderly pose several treatment dilemmas, including the increased risk of perioperative complications, the management of orthotopic neobladder or different types of urinary diversion, as well as the higher risk of adverse events caused by pelvic radiotherapy and systemic chemotherapy. Multidimensional parameters such as biologic prognostic factors, performance status, functional independence, comorbidities and cognitive function of the patient should be collected in order to tailor treatment to the patient's life expectancy and preferences. Optimized integration of TUR followed by bladder removal (or radiotherapy), with or without adjunctive chemotherapy, can be recommended for otherwise healthy patients. Palliative measures, such as TUR followed by external radiotherapy alone or monochemotherapy, should be reserved for partially impaired patients with moderate comorbidities, in order to maximize the balance of benefits and toxicities. This review summarizes recent data concerning surgery, radiotherapy and systemic chemotherapy for bladder cancer in the elderly, and discusses pros and cons of the currently available therapeutic options.

Nonplatinum therapy in advanced bladder cancer

Carcinoma of the bladder is the second most prevalent genitourinary malignancy and the fifth most common solid malignancy in the USA. Combination chemotherapy is used in most patients with advanced disease. Traditionally, on the basis of favorable response rates and survival data, cisplatin-based regimens have been the preferred chemotherapy for patients with metastatic bladder cancer. However, the toxicity profile of cisplatin precludes its use in a significant subset of patients with advanced bladder cancer. Conversely, noncisplatin-containing regimens have been shown to have a more favorable toxicity profile and to have activity in advanced bladder cancer. Here, various nonplatinum chemotherapy regimens for advanced disease are reviewed.

Recent advances in the treatment of bladder cancer

Bladder cancer continues to provide urologists and researchers with a clinical and scientific challenge. Several urinary markers used in the detection and screening of patients with bladder cancer are currently under investigation. Improvements in intravesical therapy are proving to help decrease both tumor recurrence and progression in patients with high-risk disease. In patients with organ-confined, node-negative bladder cancer, radical cystectomy provides excellent local control and long-term disease-free survival. The use of an extended lymphadenectomy at the time of cystectomy may yield improved prognostic information as well as a potential survival benefit. Neoadjuvant chemotherapy and less toxic combination chemotherapy regimens are offering potential improvements in patients with extravesical or nodal extension. The current methods of detection, as well as available therapeutic treatment options are reviewed.

Vinorelbine rescue therapy for dogs with primary urinary bladder carcinoma

The goal of this study was to evaluate the anti-tumour activity and toxicoses of vinorelbine as a palliative rescue therapy for dogs with primary urinary bladder carcinoma. Thirteen dogs refractory to prior chemotherapeutics and one dog naïve to chemotherapeutic treatment were enrolled. Vinorelbine (15 mg m(-2) IV) was administered intravenously along with concurrent oral anti-inflammatory drugs, if tolerated. A median of six doses of vinorelbine (range: 1-16) was administered. Two dogs (14%) had partial responses, and eight (57%) experienced stable disease. Subjective improvement in clinical signs was noted in 11 dogs (78%). Adverse events were mild and primarily haematological in nature. Median time to progression was 93 days (range: 20-239 days). Median survival time for all dogs was 187 days; median survival for 13 pre-treated dogs was 207 days. Vinorelbine may have utility in the management of canine primary urinary bladder carcinoma and should be evaluated in a prospective study.

Choosing chemotherapy in patients with advanced urothelial cell cancer who are unfit to receive cisplatin-based chemotherapy

Transitional cell carcinoma of the urothelial tract is the second most common cancer of the genitourinary system and the fifth most common cancer in Western countries with more than 300,000 new cases per year worldwide. Following the introduction of cisplatin-based chemotherapy, median overall survival in patients with metastatic disease has doubled, demonstrating chemotherapy as an important treatment modality in advanced or metastatic disease. Patients 'unfit' to receive cisplatin-based chemotherapy are characterized by impaired renal function, impaired performance status, and/or comorbidity that preclude the use of cisplatin. In this review we summarize the different chemotherapeutic schemes, focusing on treatment options in cisplatin 'unfit' patients.

Gemcitabine chemotherapy for the treatment of metastatic bladder carcinoma

OBJECTIVE

• To systematically review the literature on gemcitabine chemotherapy for advanced or metastatic bladder cancer.

MATERIALS AND METHODS

• The Medical Literature Analysis and Retrieval System Onlinedatabase (MEDLINE), the Excerpta Medicadatabase (EMBASE), the Cumulative Index to Nursing and Allied Health Literature database(CIHNAL), the Cochrane database of randomized trials, the Literatura Latino-Americana e do Caribe emCiências da Saúdedatabase (LILACS), and Web of Science were searched to identify trials of gemcitabine for metastatic bladder cancer. Also searched were international guidelines on metastatic prostate cancer, trial registries, and recent systematic reviews. Data on trial design, survival, tumour response and toxicity outcomes were extracted from relevant studies.

RESULTS

• This review identified six randomized trials of combined chemotherapy with gemcitabine for the management of unresectable, locally advanced or metastatic bladder cancer. • One trial compared gemcitabine plus cisplatin (GCis) with methotrexate/vinblastine/doxorubicin/cisplatin(MVAC) and found no difference in overall survival (OS; hazard ratio 1.09) but a better safety profile with GCis, which was suggested as the treatment of choice. • A second trial evaluated GCis against gemcitabine plus carboplatin (GCarbo) and reported similar median OS (12.8 vs 9.8 months), disease progression (8.3 vs 7.3 months) and tumour response rates (66% vs 56%) for the two patient groups. • A third trial compared GCis with GCis plus paclitaxel (GCisPac) and showed no significant difference in median OS (12.3 vs 15.3 months) and response rates (44% vs 43%) but greater toxicity with GCisPac. • A fourth trial assessed GCarbo against methotrexate plus carboplatin plus vinblastine in patients unfit for cisplatin-based chemotherapy and found similar tumour response rates for each regime (38% vs 20%) but the triplet regime was more toxic. • Two other randomized studies compared a 2-weekly maintenance regime of gemcitabine plus paclitaxel with a 3-weelky regime given for a maximum of six cycles and found that the maintenance schedule did not confer any additional survival benefit. • In all, 53 observational studies of gemcitabine chemotherapy were identified that varied considerably in the drug combinations used and schedules. Overall response rates (17-78%) and median OS (6.4-24.0 months) were variable with no combination being clearly superior.

CONCLUSIONS

• Gemcitabine combined chemotherapy is active in the management of metastatic bladder cancer. • GCis may be considered an alternative regime to MVAC. • GCarbo should be considered for patients unfit for cisplatin-based therapy.

Treatment of patients with metastatic urothelial cancer "unfit" for Cisplatin-based chemotherapy

PURPOSE

Cisplatin-based combination chemotherapy is considered standard first-line treatment for patients with metastatic urothelial carcinoma. However, a large proportion of patients with metastatic urothelial carcinoma are considered "unfit" for cisplatin. The purpose of this review is to define unfit patients and to identify treatment options for this subgroup of patients.

PATIENTS AND METHODS

In this review, the criteria used to define unfit patients are explored and the results of prospective clinical trials evaluating chemotherapeutic regimens in unfit patients are summarized.

RESULTS

Several phase II trials and a single, large phase III trial have explored chemotherapeutic regimens for the treatment of unfit patients with metastatic urothelial carcinoma. Heterogeneous eligibility criteria have been used to define unfit patients in these studies. A uniform definition of unfit is proposed on the basis of the results of a survey of genitourinary medical oncologists. According to this definition, unfit patients would meet at least one of the following criteria: Eastern Cooperative Oncology Group performance status of 2, creatinine clearance less than 60 mL/min, grade ≥ 2 hearing loss, grade ≥ 2 neuropathy, and/or New York Heart Association Class III heart failure.

CONCLUSION

Additional studies to optimize treatment for this important subset of patients are needed. A uniform definition of unfit patients will lead to more uniform clinical trials, enhanced ability to interpret the results of these trials, and a greater likelihood of developing a viable strategy for regulatory approval.

[Chemotherapy in unfit bladder cancer patients]

Bladder cancer often occurs in patients with high risk of acute toxicity under chemotherapy. So-called unfit patients are a heterogenous population, sharing a contra-indication for cisplatin and presenting either chronic renal failure, and/or elderly, and/or altered performance status, and/or severe co-morbidities. Therefore, it is necessary to develop chemotherapy protocols feasible in renal insufficient patients, and well tolerated in frail patients. The medical evaluation prior to initiate chemotherapy is of major importance to screen for chronic disorders and to anticipate the potential acute complications following chemotherapy. Chemotherapy of elderly patients with severe comorbidities is a common situation in bladder cancer, and will concern all cancer patients. The evaluation of the benefit/risk ratio of the chemotherapy protocol is a typical expertise of medical oncologists, which requires to integrate the complex links between the patient, the antitumor agent, and toxicity. The physician must also have a honest dialogue to inform, advise, listen to the patients priorities. Medical oncologists have to have in mind this situation and to adapt their clinic and their vocabulary to this emerging reality.

Management of bladder cancer: current and emerging strategies

Cancer of the urinary bladder is the fifth most prevalent solid tumour in the US. Urothelial carcinoma is the most common form of bladder cancer, accounting for about 90% of cases. About 25% of patients with bladder cancer have advanced disease (muscle-invasive or metastatic disease) at presentation and are candidates for systemic chemotherapy. Urothelial carcinoma is a chemo-sensitive disease, with a high overall and complete response rate to combination chemotherapy. In the setting of muscle-invasive urothelial carcinoma, use of neoadjuvant chemotherapy is associated with overall survival benefit. The role of adjuvant chemotherapy in this setting is yet to be validated. In the setting of metastatic disease, use of cisplatin-based regimens improves survival. However, despite initial high response rates, the responses are typically not durable leading to recurrence and death in the vast majority of these patients. Currently, there is no standard second-line therapy for patients in whom first-line chemotherapy for metastatic disease has failed. Many newer chemotherapeutic agents have shown modest activity in urothelial carcinoma. Improved understanding of molecular biology and pathogenesis of urothelial carcinoma has opened avenues for the use of molecularly targeted therapies, several of which are being tested in clinical trials. Currently, several novel drugs seem particularly promising including inhibitors of the epidermal growth factor receptor pathway, such as cetuximab, and inhibitors of tumour angiogenesis, such as bevacizumab and sunitinib. Development of reliable molecular predictive markers is expected to improve treatment decisions, therapy development and outcomes in urothelial carcinoma. Funding of and participation in clinical trials are key to advancing the care of urothelial cancer patients. Current and emerging strategies in the medical management of urothelial carcinoma are reviewed.

Bladder cancer

Bladder cancer is a heterogeneous disease, with 70% of patients presenting with superficial tumours, which tend to recur but are generally not life threatening, and 30% presenting as muscle-invasive disease associated with a high risk of death from distant metastases. The main presenting symptom of all bladder cancers is painless haematuria, and the diagnosis is established by urinary cytology and transurethral tumour resection. Intravesical treatment is used for carcinoma in situ and other high grade non-muscle-invasive tumours. The standard of care for muscle-invasive disease is radical cystoprostatectomy, and several types of urinary diversions are offered to patients, with quality of life as an important consideration. Bladder preservation with transurethral tumour resection, radiation, and chemotherapy can in some cases be equally curative. Several chemotherapeutic agents have proven to be useful as neoadjuvant or adjuvant treatment and in patients with metastatic disease. We discuss bladder preserving approaches, combination chemotherapy including new agents, targeted therapies, and advances in molecular biology.

Chemotherapy for Metastatic or Unresectable Bladder Cancer

Cisplatin, methotrexate, doxorubicin, and vinblastine (M-VAC) combination chemotherapy has been the historic standard of care in patients with advanced urothelial tumors. Phase III trials have evaluated new combinations such as gemcitabine/cisplatin (GC), carboplatin/paclitaxel, docetaxel/cisplatin, and interferon-alpha/5-fluorouracil/cisplatin. However, these new regimens have failed to demonstrate superiority in terms of overall survival when compared with classic M-VAC. The GC doublet has proved to be a new standard treatment alternative based on an improved toxicity profile and similar survival results. The addition of a third agent (paclitaxel) to this regimen is the focus of a phase III trial. However, long-term follow-up with classical and new regimens (doublets and triplets) still show limited efficacy and emphasize the need to identify more active treatment. For "unfit" patients, ie, those unable to receive cisplatin-based regimens, conventional regimens include methotrexate, carboplatin, and vinblastine (M-CAVI), carboplatin-gemcitabine, carboplatin-paclitaxel, gemcitabine-taxane, or monotherapy with either gemcitabine, carboplatin, or a taxane. New drugs, including pemetrexed and vinflunine, are now being studied for salvage therapy. In addition to new active drug combinations and targeted therapies, chemotherapy optimization using molecular characteristics to predict chemosensitivity is emerging.

Gemcitabine in the treatment of advanced transitional cell carcinoma of the urothelium

M-VAC (cisplatin, methotrexate, adriamycin, vinblastine) combination chemotherapy has been for long time the standard of care in fit patient with advanced urothelial tumors. Gemcitabine/cisplatin with similar results and an improved toxicity profile has proved to be a new standard alternative. Whether or not we can improve survival with newer triplet regimens will depend upon the results of ongoing phase III trials. In addition to the new active drug combinations and targeted therapies, new approaches are emerging for treatment. Chemotherapy optimization using molecular markers predicting chemosensitivity are being applied. There is an obvious need to incorporate in clinical trials a systematic translational approach to explain both our successes and our failures.

Chemotherapy for Metastatic Bladder Cancer

This paper reviews the current status of systemic chemotherapy in the management of advanced and metastatic urothelial cancer. The activity of a number of single agents and combination drug regimens is discussed, and the small number of randomised-controlled studies available is also considered. Prognostic factors for response and survival, particularly long-term survival after systemic chemotherapy, are also reviewed. Special consideration is given to the role of systemic chemotherapy as a precursor to surgery (or radiotherapy) in locally advanced disease that is initially considered incurable. Therapeutic options for patients unable to tolerate cisplatin owing to renal impairment or other comorbidities are explored. Future directions are explored, including the role of molecular phenotyping in providing prognostic information, indicators of the likely success of conventional therapeutic measures and the development of specific targeted therapies.

Bladder cancer

PURPOSE OF REVIEW

This article reviews the recent literature concerning important issues in the management of patients with bladder cancer. A brief overview of all aspects of bladder cancer including the etiology, diagnosis, and treatment are discussed with a focus on recent advances.

RECENT FINDINGS

Bladder cancer is a significant cause of morbidity and mortality. The treatment for bladder cancer should be based on individual patient risk assessment and should include a multidisciplinary approach. In patients with superficial bladder cancer, research has focused on improving and optimizing intravesical therapy to reduce tumor recurrence and progression as well as on methods to better select the most appropriate treatment for patients with high-risk features. The important prognostic and therapeutic role of lymphadenectomy during radical cystectomy has become apparent and recent work has attempted to better define what should be considered the standard for lymph node dissection. Finally, in an attempt to improve survival, advances have been made using systemic chemotherapy in both the perioperative settings as well as for treatment of metastatic bladder cancer.

SUMMARY

Research continues to improve our understanding of bladder cancer. This ongoing investigation is currently being translated to the bedside with refinements in the diagnosis and treatment of patients with bladder cancer.