Efficacy of escalating doses of intravesical interferon alpha-2b in reducing recurrence rate and progression in superficial transitional cell carcinoma

Efficacy of intravesical therapies on the prevention of recurrence and progression of non-muscle-invasive bladder cancer: A systematic review and network meta-analysis

Intravesical instillation therapy is the mainstay of prophylaxis of tumor recurrence and progression in non‐muscle‐invasive bladder cancer. However, there is no study evaluating the superiority of monotherapy. The aim of this study is to compare the efficacy of preventing recurrence and progression of intravesical monotherapies via network meta‐analysis (NMA) of randomized controlled trials. Database searches were conducted on Embase, Ovid Medline, Web of Science, ScienceDirect, Cochrane Library, and ClinicalTrials.com from the time of establishment to February 6, 2020. The monotherapies included Bacille Calmette‐Guérin (BCG), mitomycin C (MMC), interferon (IFN), adriamycin, epirubicin, gemcitabine (GEM), and thiotepa (THP). A Bayesian consistency network model was generated under a random‐effects model. The superiority of therapy was identified based on the surface under the cumulative ranking curve (SUCRA). Fifty‐seven studies with 12462 patients are included. NMA shows that GEM (SUCRA = 0.92), BCG (SUCRA = 0.82), and IFN (SUCRA = 0.78) are the top three effective drugs to reduce recurrence. GEM (SUCRA = 0.87) is the most effective therapy to prevent progress, followed by BCG, MMC, THP, and IFN with similar efficacy. Subgroup analysis of pairwise meta‐analysis and NMA was performed on publication year, trial initiation year, study origin, center involvement, sample size, drug schedule, tumor characteristics, and trial quality to address confounding factors, which suggests the robustness of the results with stable effect sizes. Network meta‐regression also indicates consistent rank by analyzing year, sample size, and quality. Compared with BCG, GEM is also a promising therapy with favorable efficacy to reduce tumor recurrence and progression. IFN and MMC could be alternative therapies for BCG with slightly inferior efficacy in recurrence prevention and similar efficacy in progression prevention. However, the results of this study should be treated with caution since most of the included studies are of moderate to high risk of bias.

Intravesical immunotherapy in nonmuscle invasive bladder cancer

Introduction:

Nonmuscle invasive urothelial cell carcinoma is the most frequent malignancy of the urinary bladder. The high recurrence rate (up to 80%) and risk of progression (up to 30%) reflect the need for long-term follow-up and sometimes multiple interventions. To reduce the rate of recurrences and tumor progression, intravesical immunotherapy, especially the use of Bacille Calmette-Guerin (BCG), represents the gold standard adjuvant treatment of high-risk nonmuscle invasive bladder cancer (NMIBC). This article reviews the role of BCG therapy and several promising new immunotherapeutic approaches such as mycobacterium phlei cell wall-nucleic acid complex, interleukin-10 (IL-10) antibody, vaccine-based therapy, alpha-emitter therapy, and photodynamic therapy checkpoint inhibitors.

Methods:

A systematic literature review was performed using the terms (immunotherapy, NMIBC, BCG, and intravesical) using PubMed and Cochrane databases.

Results:

BCG represents the most common intravesical immunotherapeutic agent for the adjuvant treatment of high-risk NMIBC. Its use is associated with a significant reduction of recurrence and progression. Patients with NMIBC of intermediate and high-risk benefit the most from BCG therapy. To achieve maximal efficacy, an induction therapy followed by a maintenance schedule should be used. Full-dose BCG is recommended to obtain ideal antitumoral activity and there is no evidence of a reduction of side effects in patients treated with a reduced dose. There are multiple new approaches and agents in immunotherapy with potential and promising antineoplastic effects.

Conclusions:

The beneficial effect of BCG is well documented and established. To reduce the tumor specific mortality, it is essential to follow guideline-based treatment. In patients with BCG-failure, there are new promising alternatives other than BCG but BCG remains the gold standard at this stage.

The effectiveness of BCG and interferon against non-muscle invasive bladder cancer: a New Zealand perspective

OBJECTIVE

To ascertain whether the current practice at Auckland City Hospital of adding interferon to BCG in patients with high risk or recurrent non-muscle invasive bladder cancer (NMIBC) unable or unwilling to undergo radical cystectomy is effective.

SUBJECTS AND METHOD

This study examined all institutional cases where BCG alone had not been effective or tolerated as primary treatment for NMIBC and the next guideline agreed step of radical cystectomy was unable to be performed. We identified all patients unwilling or unable to undergo radical cystectomy due to patient co-morbidities or preference for whom ongoing treatment and care was required and included 45 in the data analysis. Current practice at Auckland City Hospital is adding interferon α-2b to BCG for this population group and all patients that were given this therapy with at least three years of follow up data from diagnosis were included into the study. Patients were either on maintenance BCG or single dosing. Several secondary outcomes were also assessed concurrently to the primary objective.

RESULTS

This observational study showed that adding interferon to BCG proved to be an effective therapy for both treatment and salvage therapy in this patient group with 56% of the patients disease (and recurrence) free at the time of audit. 8/45 patients died whilst undergoing treatment with two of these as a direct result of bladder cancer due to disease progression.

CONCLUSION

This therapy has improved outcomes at our institution and has a place as a treatment of choice in this difficult to manage patient group.

Interferon alfa in the treatment paradigm for non-muscle-invasive bladder cancer

OBJECTIVES

In this article, we review the various options for and the potential role of interferon alfa (IFN-α) in the treatment of non-muscle-invasive bladder cancer (NMIBC).

METHODS

PubMed was searched for journal articles on IFN-α use in treating bladder cancer. The references listed in the National Comprehensive Cancer Network guidelines were used as a guide to identify relevant publications on treatments for NMIBC.

RESULTS

Transurethral resection with adjuvant intravesical chemotherapy or immunotherapy is the standard treatment option for NMIBC. Adjuvant IFN-α therapy has limited efficacy in preventing recurrences in intermediate-risk and high-risk patients; bacillus Calmette-Guérin (BCG) monotherapy is the recommended first-line treatment in these patients. Unfortunately, cancer progression or recurrence is a common outcome; radical cystectomy, which is often the lifesaving approach in such a scenario, is associated with significant morbidity, mortality, and decreased quality of life. Current alternatives to cystectomy include repeat intravesical immunotherapy, conventional instillation chemotherapy, and device-assisted intravesical chemotherapy. The efficacy of any chemotherapy after BCG failure, either conventional or device assisted, has not been established. BCG and IFN-α combination intravesical therapy has not been investigated thoroughly; based on available data, combination therapy appears to be most effective in patients with carcinoma in situ and may be preferentially considered as an alternative to radical cystectomy for patients with intermediate-risk or high-risk NMIBC who do not tolerate the standard BCG dose or experience BCG failure after 1 year of therapy. However, this approach requires close follow-up and should only be chosen after careful consideration of all risk factors.

CONCLUSIONS

There is a lack of efficacious treatment options for patients with NMIBC recurrence or progression after initial BCG treatment. There is a need for well-designed clinical trials investigating the safety and efficacy of available therapies, including BCG and IFN-α2b combination therapy.

Practical Applications of Intravesical Chemotherapy and Immunotherapy in High-risk Patients with Superficial Bladder Cancer

The following steps are practical in the treatment of intermediate-to-high risk patients with superficial bladder cancer: Resect all visible tumor at the time of first TUR of bladder tumor. Strongly consider re-resection, especially for high-risk, large, multifocal, stage T1 tumors. Apply one dose of cytotoxic chemotherapy perioperatively within 6 hours of TUR (ideally immediately). Once histopathology is available, consider intravesical induction chemotherapy for intermediate-risk patients and BCG for intermediate- or high-risk patients and those having failed prior chemotherapy. At least 1 year of maintenance therapy should be planned for all intermediate-to-high risk BCG-treated patients. Chemotherapy maintenance may be useful if perioperative chemotherapy was omitted. For patients failing standard therapy, a thorough discussion of the risks (including progression and metastasis) and expected benefits should take place before the initiation of salvage therapy. The radical cystectomy option should be openly entertained. Consider BCG plus interferon or gemcitabine-based salvage programs if appropriate. Explore clinical trial options. Contact urologic cancer experts for guidance and advice.

Immunotherapy for superficial bladder cancer

The treatment of superficial bladder cancer requires adjuvant therapies besides transurethral resection because of a high recurrence rate after this standard treatment alone. Current adjuvant therapies involve intravesical chemotherapy for patients at low and intermediate risk for recurrence and progression, and intravesical bacillus Calmette-Guérin for patients at intermediate and high risk. However, these adjuvant therapies fail in a significant number of patients, dictating the need for new and improved adjuvant treatment modalities for superficial bladder cancer. Immunotherapy aiming at the modulation of the immune system of the patient is a promising alternative adjuvant. This review discusses the current status of the clinical development of various immunotherapy approaches for superficial bladder cancer, including passive immunotherapy, immune stimulants, immunogene therapy and cancer vaccination.

Changes in end products of nitric oxide in urine and induction of nitric oxide synthase expression in urinary bladder during intravesical instillations of IFN-alpha2b

Interferon-alpha2b (IFN-alpha2b) is being used intravesically for preventing recurrence and progression of superficial transitional cell carcinoma of the bladder. However, its mechanism of action when instilled intravesically is not yet elucidated. We monitored end products of nitric oxide (NO) in urine in 12 bladder cancer patients undergoing intravesical instillations of IFN-alpha2b. Urine end products of NO levels rose gradually after each instillation, reaching a peak value after the third instillation. Although the patients continued their treatment for 5 more weeks, no further alteration was observed. Inducible nitric oxide synthase (iNOS) expression was immunohistochemically evaluated in urinary bladder biopsy specimens before and after IFN-alpha2b instillations. It was shown that IFN-alpha2b induced urothelial iNOS expression, with subsequent oxidative stress. The peroxynitrite (ONOO-) formed from the combination of NO with superoxide (O2-) provides important clues in the role of ONOO- as a causative factor in the antineoplastic action of IFN-alpha2b.

Adjuvant Intravesical Mitoxantrone versus Recombinant Interferon-α after Transurethral Resection of Superficial Bladder Cancer: A Randomized Prospective Study

OBJECTIVE

To determine the efficacy and safety of two different doses of intravesical mitoxantrone and of recombinant interferon-alpha (IFNalpha-2b), instilled after transurethral resection (TUR) of superficial transitional cell carcinoma (TCC) of the bladder.

MATERIAL AND METHODS

208 patients (mean age 62.05 years) with primary or recurrent superficial (TaG1, T1G1, T1G2) bladder cancer were randomly allocated into four groups, after TUR of all visible tumors. Group A (45 patients) received no further therapy; group B (56 patients) received 10 mg of mitoxantrone (6 weekly and 20 fortnightly instillations), group C (54 patients) 20 mg of mitoxantrone (3 fortnightly and 10 monthly instillations) and group D (53 patients) received 100 MU of IFNalpha-2b (8 weekly, 8 fortnightly and 6 monthly instillations).

RESULTS

During the follow-up (mean 21.09 months), 29 (64.44%) patients in group A had recurrence, compared with 19 (33.92%) in group B, 17 (31.48%) in group C and 15 (28.3%) patients in group D (p < 0.005). Furthermore, the differences in simple recurrence rates were statistically more significant (p < 0.05), when group A was compared with the three other groups in the terms of T1G2, recurrent and multiple neoplasms. Twenty-nine patients (10, 7, 8, and 4 in groups A-D) experienced tumor progression, and the differences between the four groups were not statistically significant (p > 0.05). The mean recurrence time was 9.03 months in group A, 13.74 in group B, 14.24 in group C and 17.4 months in group D (p < 0.001), and the recurrence rate per 100 patient-months was 4.39, 1.57, 1.48 and 1.06, respectively (p < 0.05). Toxicity (grade 1-3) was recorded in 23.21% in group B, in 31.48% in group C and in 9.43% in group D (p < 0.01).

CONCLUSION

The two doses of mitoxantrone resulted in similar efficacy for the prevention of superficial bladder cancer recurrences, with the dose of 10 mg of mitoxantrone being related to fewer side effects. In comparison with mitoxantrone, the adjuvant intravesical immunotherapy with 100 MU of IFNalpha-2b showed a better combination of efficacy and safety.

Potential of interferon-alpha in solid tumours: part 2

The second part of this review examines the use of recombinant interferon-alpha (rIFNalpha) in the following solid tumours: superficial bladder cancer, Kaposi's sarcoma, head and neck cancer, gastrointestinal cancers, lung cancer, mesothelioma and ovarian, breast and cervical malignancies. In superficial bladder cancer, intravesical rIFNalpha has a promising role as second-line therapy in patients resistant or intolerant to intravesical bacille Calmette-Guérin (BCG). In HIV-associated Kaposi's sarcoma, rIFNalpha is active as monotherapy and in combination with antiretroviral agents, especially in patients with CD4 counts >200/mm(3), no prior opportunistic infections and nonvisceral disease. rIFNalpha has shown encouraging results when used in combination with retinoids in the chemoprevention of head and neck squamous cell cancers. It is effective in the chemoprevention of hepatocellular cancer in hepatitis C-seropositive patients. In neuroendocrine tumours, including carcinoid tumour, low-dosage (</=3 MU) or intermediate-dosage (5 to 10 MU) rIFNalpha is indicated as second-line treatment, either with octreotide or alone in patients resistant to somatostatin analogues. Intracavitary IFNalpha may be useful in malignant pleural effusions from mesothelioma. Similarly, intraperitoneal IFNalpha may have a role in the treatment of minimal residual disease in ovarian cancer. In breast cancer, the only possible role for IFNalpha appears to be intralesional administration for resistant disease. IFNalpha may have a role as a radiosensitising agent for the treatment of cervical cancer; however, this requires confirmation in randomised trials. On the basis of current evidence, the routine use of rIFNalpha is not recommended in the therapy of head and neck squamous cell cancers, upper gastrointestinal tract, colorectal and lung cancers, or mesothelioma. Pegylated IFNalpha (peginterferon-alpha) is an exciting development that offers theoretical advantages of increased efficacy, reduced toxicity and improved compliance. Further data from randomised studies in solid tumours are needed where rIFNalpha has activity, such as neuroendocrine tumours, minimal residual disease in ovarian cancer, and cervical cancer. A better understanding of the biological mechanisms that determine response to rIFNalpha is needed. Studies of IFNalpha-stimulated gene expression, which are now feasible, should help to identify molecular predictors of response and allow us to target therapy more selectively to patients with solid tumours responsive to IFNalpha.

Intravesical instillations of interferon gamma in the prophylaxis of high risk superficial bladder cancer--results of a controlled prospective study

OBJECTIVE

To determine if intravesically administered recombinant interferon (IFN) gamma may serve as adjuvant first line treatment in prophylaxis of superficial bladder cancer by reducing its risk for recurrence, in the short term.

MATERIAL AND METHODS

A total of 54 patients (43 males and 11 females) with superficial bladder tumours (Ta/T1) initially treated with transurethral resection for their tumors were randomized into two groups: Twenty-eight patients were left untreated after the transurethral resection (controls) whereas 26 patients received intravesical IFN gamma adjuvantly, at a dosage of 0.7 mg per week for 8 weeks. Patients with G1 tumors and carcinoma in situ were excluded. The follow up had a mean time of 12.1 months. Recurrence or progression, as terminal events of the study, were recorded. The comparison of the recurrences between the two groups was performed by estimating: (a) the simple recurrence rate, and (b) the interval to tumor recurrence in each group.

RESULTS

Tumor recurrence was detected in 24 controls (86%) and in 16 (62%) patients of the IFN gamma group (p = 0.043). The comparison of the Kaplan-Meier disease-free survival curves between the two groups of patients indicated that intravesical instillations of IFN gamma exerted a continuous protective effect to those who received the agent, in the follow up period (p = 0.0237). No serious side-effects were noted.

CONCLUSIONS

Intravesically administered IFN gamma has a demonstrable protective role as first line adjuvant treatment in superficial bladder cancer. This role is mainly focused on prevention of recurrences in the short term. Further prospective studies with longer follow up are required, in order to define the exact place of the drug in the urologist's armamentarium.

A randomized comparative dose-ranging study of interferon-alpha and mitomycin-C as an internal control in primary or recurrent superficial transitional cell carcinoma of the bladder

OBJECTIVE

To compare, in a phase II study, the activity and toxicity of three dose levels of interferon-alpha, and of mitomycin-C given intravesically (as an internal control to validate the results), the primary objective being to investigate the percentage of complete responses (complete disappearance of a marker lesion) induced by the three interferon-alpha dose levels on a marker lesion; a secondary objective was to compare the interferon-alpha doses for toxicity.

PATIENTS AND METHODS

In all, 115 patients were enrolled, with the inclusion criteria being multiple grade 1 or 2, stage Ta or T1, primary or recurrent transitional cell carcinoma of the bladder. Interferon-alpha (30, 50 and 80 MU) and mitomycin-C (40 mg) intravesical treatments were given as follows. Patients randomized to one of three interferon-alpha dose levels were treated weekly for 12 weeks. However, in week 9 (first cystoscopy after baseline) interferon-alpha treatment was stopped if there was a complete response or disease progression. Patients randomized to mitomycin-C were treated weekly for 8 weeks only and in week 9 underwent follow-up cystoscopy.

RESULTS

Interferon-alpha at doses of 30, 50 and 80 MU gave response rates at 13 weeks of 19%, 33% and 41%, respectively. Although the response rates were higher for 50 and 80 MU than for 30 MU, the differences were not statistically significant. All three interferon-alpha groups had significantly lower response rates than the internal control, mitomycin-C (72%). The safety analysis showed that most of the adverse events were of mild to moderate severity. Adverse events were experienced by 37%, 37% and 48% of patients receiving 30, 50 and 80 MU interferon-alpha, respectively, and by 55% of patients receiving mitomycin-C. The corresponding rates for severe adverse events related to treatment were 9% for interferon-alpha and 10% for mitomycin-C.

CONCLUSION

Ablative therapy with interferon-alpha was less effective than mitomycin-C in patients with superficial bladder cancer. Both drugs were well tolerated, although interferon-alpha appeared to have a slightly better overall safety profile.

Interferons and bladder cancer

With the introduction of BCG, intravesical instillation of immunotherapeutic agents has become a mainstay of therapy in the treatment of superficial bladder cancer. Interferon is capable of inducing a non-specific cellular and humoral immune response towards tumor cells. It has shown promise in reducing the recurrence and progression rates of superficial bladder cancer. In contrast to BCG, intravesical interferon is associated with minimal side effects and a very low dropout rate. Current research has focused on the use of interferon in combination with immunotherapeutic and cytotoxic drugs.