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Passarelli R, Packiam VT. Contemporary Treatment of NMIBC-Is It Time to Move on from BCG? J Clin Med 2024; 13:4112. [PMID: 39064152 PMCID: PMC11277665 DOI: 10.3390/jcm13144112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 07/09/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Non-muscle-invasive bladder cancer (NMIBC) encompasses approximately three-quarters of all bladder cancer (BC) diagnoses. Intravesical Bacillus Calmette-Guerin (BCG) has been the long-standing gold standard treatment for patients following endoscopic resection. However, despite reasonable efficacy, recurrence rates are still suboptimal, and this, combined with treatment tolerability and BCG shortages, has prompted an investigation into alternative treatment modalities. Advances in this landscape have been predominantly for patients with BCG-unresponsive disease, and there are currently four FDA-approved treatments for these patients. More recently, trials have emerged looking for alternatives to BCG for patients who are treatment-naïve. We performed a literature search via PubMed to find recent publications on alternatives to BCG, as well as a search on clinicaltrials.gov and recent conference presentations for ongoing clinical trials. Studies have shown that combination intravesical chemotherapy, combination intravesical therapy with BCG, and combination intravenous therapy with BCG preliminarily have good efficacy and safety profiles in this disease space. Ongoing trials are underway, and we anticipate as these studies mature, there will be a shift in NMIBC treatment regimens.
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Affiliation(s)
- Rachel Passarelli
- Division of Urology, Rutgers Robert Wood Johnson, New Brunswick, NJ 08901, USA;
| | - Vignesh T. Packiam
- Division of Urology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
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2
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Ben-David R, Tillu N, Alerasool P, Bieber C, Ranti D, Tolani S, Eisenhauer J, Chung R, Lavallée E, Waingankar N, Attalla K, Wiklund P, Mehrazin R, Anderson CB, Sfakianos JP. Induction and maintenance of sequential intravesical gemcitabine/docetaxel for intermediate and high-risk non-muscle invasive bladder cancer with different dosage protocols. World J Urol 2024; 42:315. [PMID: 38734774 DOI: 10.1007/s00345-024-04992-5] [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: 10/25/2023] [Accepted: 04/11/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION The combination of sequential intravesical gemcitabine and docetaxel (Gem/Doce) chemotherapy has been considered a feasible option for BCG (Bacillus Calmette-Guérin) treatment in non-muscle invasive bladder cancer (NMIBC), gaining popularity during BCG shortage period. We seek to determine the efficacy of the treatment by comparing Gem/Doce induction alone vs induction with maintenance, and to evaluate the treatment outcomes of two different dosage protocols. METHODS A bi-center retrospective analysis of consecutive patients treated with Gem/Doce for NMIBC between 2018 and 2023 was performed. Baseline characteristics, risk group stratification (AUA 2020 guidelines), pathological, and surveillance reports were collected. Kaplan-Meier survival analysis was performed to detect Recurrence-free survival (RFS). RESULTS Overall, 83 patients (68 males, 15 females) with a median age of 73 (IQR 66-79), and a median follow-up time of 18 months (IQR 9-25), were included. Forty-one had an intermediate-risk disease (49%) and 42 had a high-risk disease (51%). Thirty-seven patients (45%) had a recurrence; 19 (23%) had a high-grade recurrence. RFS of Gem/Doce induction-only vs induction + maintenance was at 6 months 88% vs 100%, at 12 months 71% vs 97%, at 18 months 57% vs 91%, and at 24 months 31% vs 87%, respectively (log-rank, p < 0.0001). Patients who received 2 g Gemcitabine with Docetaxel had better RFS for all-grade recurrences (log-rank, p = 0.017). However, no difference was found for high-grade recurrences. CONCLUSION Gem/Doce induction with maintenance resulted in significantly better RFS than induction-only. Combining 2 g gemcitabine with docetaxel resulted in better RFS for all-grade but not for high-grade recurrences. Further prospective trials are necessary to validate our results.
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Affiliation(s)
- Reuben Ben-David
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA.
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA.
| | - Neeraja Tillu
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | - Parissa Alerasool
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Christine Bieber
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Daniel Ranti
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Serena Tolani
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Justin Eisenhauer
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Rainjade Chung
- Department of Urology, Columbia University Irving Medical Center, New York, NY, USA
| | - Etienne Lavallée
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
| | - Nikhil Waingankar
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | - Kyrollis Attalla
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
| | | | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, The Milton and Carroll Petrie, New York, NY, USA
- Department of Urology, Ichan School of Medicine at Mount Sinai, Tisch Cancer Institute, 1425 Madison Avenue, New York, NY, USA
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Choi J, Kim KH, Kim HS, Yoon HS, Kim JH, Kim JW, Lee YS, Choi SY, Chang IH, Ko YH, Song W, Jeong BC, Nam JK. Comparative analysis of recurrence rates between intravesical gemcitabine and bacillus Calmette-Guérin induction therapy following transurethral resection of bladder tumors in patients with intermediate- and high-risk bladder cancer: A retrospective multicenter study. Investig Clin Urol 2024; 65:248-255. [PMID: 38714515 PMCID: PMC11076792 DOI: 10.4111/icu.20230313] [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: 09/13/2023] [Revised: 01/03/2024] [Accepted: 03/04/2024] [Indexed: 05/10/2024] Open
Abstract
PURPOSE This study investigated the efficacy of intravesical gemcitabine as an alternative to bacillus Calmette-Guérin (BCG) therapy. MATERIALS AND METHODS Data were retrospectively collected across seven institutions from February 1999 to May 2023. Inclusion criteria included patients with intermediate- or high-risk non-muscle invasive bladder cancer (NMIBC) who underwent transurethral resection of bladder tumors (TURBT) and received at least four sessions of intravesical gemcitabine or BCG induction therapy. Patient characteristics, complete remission (CR), occurrence, and progression rates were compared. RESULTS In total, 149 patients were included in this study (gemcitabine, 63; BCG, 86). No differences were apparent between the two groups in baseline characteristics, except for the follow-up period (gemcitabine, 9.2±5.9 months vs. BCG, 43.9±41.4 months, p<0.001). There were no consistent significant differences observed between the two groups in the 3-month (gemcitabine, 98.4% vs. BCG, 95.3%; p=0.848), 6-month (94.9% vs. 90.0%, respectively; p=0.793) and 1-year CR rates (84.2% vs. 83.3%, respectively; p=0.950). Also, there was no significant statistical difference in progression-free survival between the two groups (p=0.953). The occurrence rates of adverse events were similar between the groups (22.2% vs. 22.1%; p=0.989); however, the rate of Clavien-Dindo grade 2 or higher was significantly higher in the BCG group (1.6% vs. 16.3%, respectively; p<0.001). CONCLUSIONS Intravesical gemcitabine demonstrated efficacy comparable to BCG therapy for the first year in patients with intermediate- and high-risk NMIBC. However, long-term follow-up studies are warranted.
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Affiliation(s)
- Joongwon Choi
- Department of Urology, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Kyung Hwan Kim
- Department of Urology, Pusan National University Hospital, School of Medicine, Pusan National University, Busan, Korea
| | - Hyung Suk Kim
- Department of Urology, Dongguk University Ilsan Medical Center, Dongguk University College of Medicine, Goyang, Korea
| | - Hyun Sik Yoon
- Department of Urology, Dongguk University Ilsan Medical Center, Dongguk University College of Medicine, Goyang, Korea
| | - Jung Hoon Kim
- Department of Urology, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Jin Wook Kim
- Department of Urology, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Yong Seong Lee
- Department of Urology, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Korea
| | - Se Young Choi
- Department of Urology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - In Ho Chang
- Department of Urology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Young Hwii Ko
- Department of Urology, Yeungnam University College of Medicine, Daegu, Korea
| | - Wan Song
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Kil Nam
- Department of Urology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Korea.
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Sturm S, Niegisch G, Windolf J, Suschek CV. Exposure of Bladder Cancer Cells to Blue Light (λ = 453 nm) in the Presence of Riboflavin Synergistically Enhances the Cytotoxic Efficiency of Gemcitabine. Int J Mol Sci 2024; 25:4868. [PMID: 38732087 PMCID: PMC11084806 DOI: 10.3390/ijms25094868] [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: 03/12/2024] [Revised: 04/25/2024] [Accepted: 04/28/2024] [Indexed: 05/13/2024] Open
Abstract
Non-muscle invasive bladder cancer is a common tumour in men and women. In case of resistance to the standard therapeutic agents, gemcitabine can be used as off-label instillation therapy into the bladder. To reduce potential side effects, continuous efforts are made to optimise the therapeutic potential of drugs, thereby reducing the effective dose and consequently the pharmacological burden of the medication. We recently demonstrated that it is possible to significantly increase the therapeutic efficacy of mitomycin C against a bladder carcinoma cell line by exposure to non-toxic doses of blue light (453 nm). In the present study, we investigated whether the therapeutically supportive effect of blue light can be further enhanced by the additional use of the wavelength-specific photosensitiser riboflavin. We found that the gemcitabine-induced cytotoxicity of bladder cancer cell lines (BFTC-905, SW-1710, RT-112) was significantly enhanced by non-toxic doses of blue light in the presence of riboflavin. Enhanced cytotoxicity correlated with decreased levels of mitochondrial ATP synthesis and increased lipid peroxidation was most likely the result of increased oxidative stress. Due to these properties, blue light in combination with riboflavin could represent an effective therapy option with few side effects and increase the success of local treatment of bladder cancer, whereby the dose of the chemotherapeutic agent used and thus the chemical load could be significantly reduced with similar or improved therapeutic success.
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Affiliation(s)
- Sofia Sturm
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Günter Niegisch
- Department of Urology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Joachim Windolf
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Christoph V. Suschek
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
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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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Lidagoster S, Ben-David R, De Leon B, Sfakianos JP. BCG and Alternative Therapies to BCG Therapy for Non-Muscle-Invasive Bladder Cancer. Curr Oncol 2024; 31:1063-1078. [PMID: 38392073 PMCID: PMC10888316 DOI: 10.3390/curroncol31020079] [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: 12/28/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
Bladder cancer is a heterogeneous disease. Treatment decisions are mostly decided based on disease stage (non-muscle invasive or muscle invasive). Patients with muscle-invasive disease will be offered a radical treatment combined with systemic therapy, while in those with non-muscle-invasive disease, an attempt to resect the tumor endoscopically will usually be followed by different intravesical instillations. The goal of intravesical therapy is to decrease the recurrence and/or progression of the tumor. In the current landscape of bladder cancer treatment, BCG is given intravesically to induce an inflammatory response and recruit immune cells to attack the malignant cells and induce immune memory. While the response to BCG treatment has changed the course of bladder cancer management and spared many "bladders", some patients may develop BCG-unresponsive disease, leaving radical surgery as the best choice of curative treatment. As a result, a lot of effort has been put into identifying novel therapies like systemic pembrolizumab and Nadofaragene-Firadenovac to continue sparing bladders if BCG is ineffective. Moreover, recent logistic issues with BCG production caused a worldwide BCG shortage, re-sparking interest in alternative BCG treatments including mitomycin C, sequential gemcitabine with docetaxel, and others. This review encompasses both the historic and current role of BCG in the treatment of non-muscle-invasive bladder cancer, revisiting BCG alternative therapies and reviewing the novel therapeutics that were approved for the BCG-unresponsive stage or are under active investigation.
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Affiliation(s)
- Sarah Lidagoster
- Department of Urology, Ichan School of Medicine at the Mount Sinai Hospital, New York, NY 10029, USA (R.B.-D.); (B.D.L.)
- CUNY School of Medicine, City College of New York, New York, NY 10031, USA
| | - Reuben Ben-David
- Department of Urology, Ichan School of Medicine at the Mount Sinai Hospital, New York, NY 10029, USA (R.B.-D.); (B.D.L.)
| | - Benjamin De Leon
- Department of Urology, Ichan School of Medicine at the Mount Sinai Hospital, New York, NY 10029, USA (R.B.-D.); (B.D.L.)
- SUNY Downstate Health Science University, New York, NY 11203, USA
| | - John P. Sfakianos
- Department of Urology, Ichan School of Medicine at the Mount Sinai Hospital, New York, NY 10029, USA (R.B.-D.); (B.D.L.)
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Catto JWF, Tran B, Rouprêt M, Gschwend JE, Loriot Y, Nishiyama H, Redorta JP, Daneshmand S, Hussain SA, Cutuli HJ, Procopio G, Guadalupi V, Vasdev N, Naini V, Crow L, Triantos S, Baig M, Steinberg G. Erdafitinib in BCG-treated high-risk non-muscle-invasive bladder cancer. Ann Oncol 2024; 35:98-106. [PMID: 37871701 DOI: 10.1016/j.annonc.2023.09.3116] [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: 09/19/2023] [Accepted: 09/29/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND Treatment options are limited for patients with high-risk non-muscle-invasive bladder cancer (NMIBC) with disease recurrence after bacillus Calmette-Guérin (BCG) treatment and who are ineligible for/refuse radical cystectomy. FGFR alterations are commonly detected in NMIBC. We evaluated the activity of oral erdafitinib, a selective pan-fibroblast growth factor receptor (FGFR) tyrosine kinase inhibitor, versus intravesical chemotherapy in patients with high-risk NMIBC and select FGFR3/2 alterations following recurrence after BCG treatment. PATIENTS AND METHODS Patients aged ≥18 years with recurrent, BCG-treated, papillary-only high-risk NMIBC (high-grade Ta/T1) and select FGFR alterations refusing or ineligible for radical cystectomy were randomized to 6 mg daily oral erdafitinib or investigator's choice of intravesical chemotherapy (mitomycin C or gemcitabine). The primary endpoint was recurrence-free survival (RFS). The key secondary endpoint was safety. RESULTS Study enrollment was discontinued due to slow accrual. Seventy-three patients were randomized 2 : 1 to erdafitinib (n = 49) and chemotherapy (n = 24). Median follow-up for RFS was 13.4 months for both groups. Median RFS was not reached for erdafitinib [95% confidence interval (CI) 16.9 months-not estimable] and was 11.6 months (95% CI 6.4-20.1 months) for chemotherapy, with an estimated hazard ratio of 0.28 (95% CI 0.1-0.6; nominal P value = 0.0008). In this population, safety results were generally consistent with known profiles for erdafitinib and chemotherapy. CONCLUSIONS Erdafitinib prolonged RFS compared with intravesical chemotherapy in patients with papillary-only, high-risk NMIBC harboring FGFR alterations who had disease recurrence after BCG therapy and refused or were ineligible for radical cystectomy.
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Affiliation(s)
- J W F Catto
- Department of Oncology and Metabolism, University of Sheffield, Sheffield; Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.
| | - B Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - M Rouprêt
- Department of Urology, GRC 5 Predictive Onco-Uro, Hôpital Pitié-Salpêtrière, Sorbonne University, Paris, France
| | - J E Gschwend
- Department of Urology, School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - Y Loriot
- Department of Cancer Medicine, INSERM U981, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - H Nishiyama
- Department of Urology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - J P Redorta
- Department of Urology, Fundació Puigvert, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - S Daneshmand
- Department of Urology, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, USA
| | - S A Hussain
- Department of Oncology and Metabolism, University of Sheffield, Sheffield; Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - H J Cutuli
- Uro-oncology and Research Unit, Sirio Libanes Hospital, Buenos Aires, Argentina
| | - G Procopio
- Oncologia Medica Genitourinaria, Fondazione IRCCS Istituto Nazionale Tumori Milano, Milan, Italy
| | - V Guadalupi
- Oncologia Medica Genitourinaria, Fondazione IRCCS Istituto Nazionale Tumori Milano, Milan, Italy
| | - N Vasdev
- Hertfordshire and Bedfordshire Urological Cancer Centre, Lister Hospital, East and North Herts NHS Trust, Stevenage; School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - V Naini
- Janssen Research & Development, San Diego
| | - L Crow
- Janssen Research & Development, Spring House
| | - S Triantos
- Janssen Research & Development, Spring House
| | - M Baig
- Janssen Research & Development, Spring House
| | - G Steinberg
- Department of Urology, Rush University Medical Center, Chicago, USA
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Chu C, Pietzak E. Immune mechanisms and molecular therapeutic strategies to enhance immunotherapy in non-muscle invasive bladder cancer: Invited review for special issue "Seminar: Treatment Advances and Molecular Biology Insights in Urothelial Carcinoma". Urol Oncol 2023; 41:398-409. [PMID: 35811207 PMCID: PMC10167944 DOI: 10.1016/j.urolonc.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 03/12/2022] [Accepted: 05/07/2022] [Indexed: 11/26/2022]
Abstract
Intravesical immunotherapy with Bacillus Calmette-Guérin (BCG) has been the standard of care for patients with high-risk non non-muscle invasive bladder cancer (NMIBC) for over four decades. Despite its success as a cancer immunotherapy, disease recurrence and progression remain common. Current efforts are focused on developing effective and well-tolerated alternatives to BCG and salvage bladder preservation therapies after BCG has failed. The focus of this review is to synthesize our current understanding of the molecular biology and tumor immune microenvironment of NMIBC to provide rationale for existing and emerging therapeutic targets. We highlight recent and ongoing clinical trials and define the current treatment landscape, challenges, and future directions of salvage treatment. Combination regimens that are rationally designed will be needed to make meaningful therapeutic advancements. Investigations into the molecular underpinnings of NMIBC are leading to the emergence of predictive molecular biomarkers that provide greater insight into the clinical heterogeneity of NMIBC and enable us to identify drivers of treatment resistance and new therapeutic targets.
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Affiliation(s)
- Carissa Chu
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eugene Pietzak
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Weill Cornell Medical College, New York, NY.
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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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11
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Kawada T, Yanagisawa T, Bekku K, Laukhtina E, von Deimling M, Chlosta M, Pradere B, Teoh JYC, Babjuk M, Araki M, Shariat SF. The efficacy and safety outcomes of lower dose BCG compared to intravesical chemotherapy in non-muscle-invasive bladder cancer: A network meta-analysis. Urol Oncol 2023:S1078-1439(23)00118-7. [PMID: 37137745 DOI: 10.1016/j.urolonc.2023.04.003] [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: 02/09/2023] [Accepted: 04/01/2023] [Indexed: 05/05/2023]
Abstract
This study aimed to assess both efficacy and safety outcomes of lowering the dose of BCG compared to intravesical chemotherapies in non-muscle-invasive bladder cancer (NMIBC) patients using a systematic review, meta-analysis, and network meta-analysis approach. A comprehensive literature search was performed through Pubmed®, Web of Science™, and Scopus® in December 2022 to identify randomized controlled trials comparing the oncologic and/or safety outcomes of reduced dose intravesical BCG and/or intravesical chemotherapies according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement. The outcomes of interest were risk of recurrence, progression, treatment-related adverse events, and discontinuation. Overall, 24 studies were eligible for quantitative synthesis. Among 22 studies that adopted induction followed by maintenance intravesical therapy, with reference to the lower-dose BCG, epirubicin was associated with a significantly higher risk of recurrence (Odds ratio [OR]: 2.82, 95% CI: 1.54-5.15), but not other intravesical chemotherapies. There were no significant differences in risk of progression among the intravesical therapies. On the other hand, standard-dose BCG was associated with a higher risk of any AEs (OR: 1.91, 95% CI: 1.07-3.41) but other intravesical chemotherapies had a comparable risk of AEs compared to lower-dose BCG. The discontinuation rate did not significantly differ between lower-dose and standard-dose BCG (OR: 1.40, 95% CI: 0.81-2.43) as well as other intravesical. According to the surface under the cumulative ranking curve, gemcitabine, and standard-dose BCG were preferable to lower-dose BCG in terms of recurrence risk; gemcitabine was also preferable to lower-dose BCG in terms of risk of AEs. In patients with NMIBC, lowering the dose of BCG decreases the risks of AEs and discontinuation rate compared to standard-dose BCG, but there is no difference in these endpoints compared to other intravesical chemotherapies. Standard-dose of BCG is preferred for all intermediate and high-risk NMIBC patients based on oncologic efficacy; however, lower-dose BCG and intravesical chemotherapies, especially gemcitabine, could be considered a reasonable alternative to BCG in selected patients who suffer from significant AEs or in case standard-dose BCG is not available.
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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, Japan
| | - 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
| | - Kensuke Bekku
- 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, Japan
| | - Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Markus von Deimling
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcin Chlosta
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Jagiellonian University Medical College, Cracow, Poland
| | - Benjamin Pradere
- Department of Urology UROSUD, La Croix Du Sud Hospital, Quint Fonsegrives, France
| | - Jeremy Yuen-Chun Teoh
- Department of Surgery, S.H. Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Marko Babjuk
- Department of Urology, Second Faculty of Medicine of Charles University, University Hospital Motol, Prague, Czech Republic
| | - Motoo Araki
- Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - 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, TX; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria.
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12
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Cheng W, Zhou Y, Chu X, Huang S, Zheng X, Zheng H. Effect of intravesical mitomycin compared with gemcitabine on the treatment non-muscle invasive bladder cancer: A meta-analysis. Actas Urol Esp 2023; 47:92-98. [PMID: 36586485 DOI: 10.1016/j.acuroe.2022.12.003] [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: 12/14/2021] [Accepted: 03/06/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION We performed a meta-analysis to evaluate the effect of intravesical mitomycin compared with gemcitabine on the treatment of non-muscle invasive bladder cancer. METHODS A systematic literature search up to November 2021 was done and 6 studies included 389 subjects with non-muscle invasive bladder cancer at the start of the study; 197 of them were provided with intravesical-mitomycin and 192 with intravesical gemcitabine. The studies reported the relationships about the effect of intravesical mitomycin compared with gemcitabine on the treatment of non-muscle invasive bladder cancer. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the effect of intravesical mitomycin compared with gemcitabine on the treatment of non-muscle invasive bladder cancer using the dichotomous method with a random or fixed-effect model. RESULTS Intravesical mitomycin had significantly higher recurrence rates (OR, 2.41; 95% CI, 1.43-4.08, p=0.001) and chemical cystitis (OR, 4.39; 95% CI, 2.27-8.51, p<0.001) compared to intravesical gemcitabine in subjects with non-muscle invasive bladder cancer. However, intravesical mitomycin had no significant difference in its effect on hematuria (OR, 1.71; 95% CI, 0.68-4.33, p=0.26), skin reaction (OR, 2.04; 95% CI, 0.59-7.07, p=0.26), and liver and kidney functions damage (OR, 1.96; 95% CI, 0.35-10.96, p=0.44) compared to intravesical gemcitabine in subjects with non-muscle invasive bladder cancer. CONCLUSIONS Intravesical mitomycin had significantly higher recurrence rates and chemical cystitis and no significant difference in its effect on hematuria, skin reaction, and liver and kidney functions damage compared to intravesical gemcitabine in subjects with non-muscle invasive bladder cancer. Further studies are required to validate these findings.
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Affiliation(s)
- W Cheng
- Department of Urology, The Fifth Affiliated Hospital of Sun Yet-sun University, Zhuhai, Guangdong, China
| | - Y Zhou
- Department of Urology, The Fifth Affiliated Hospital of Sun Yet-sun University, Zhuhai, Guangdong, China
| | - X Chu
- Department of Urology, The Fifth Affiliated Hospital of Sun Yet-sun University, Zhuhai, Guangdong, China
| | - S Huang
- Department of Urology, The Fifth Affiliated Hospital of Sun Yet-sun University, Zhuhai, Guangdong, China
| | - X Zheng
- Department of Urology, The Fifth Affiliated Hospital of Sun Yet-sun University, Zhuhai, Guangdong, China.
| | - H Zheng
- Department of Urology, The Fifth Affiliated Hospital of Sun Yet-sun University, Zhuhai, Guangdong, China
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13
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Joshi M, Atlas SJ, Beinfeld M, Chapman RH, Rind DM, Pearson SD, Touchette DR. Cost-Effectiveness of Nadofaragene Firadenovec and Pembrolizumab in Bacillus Calmette-Guérin Immunotherapy Unresponsive Non-Muscle Invasive Bladder Cancer. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022:S1098-3015(22)04779-9. [PMID: 36529422 DOI: 10.1016/j.jval.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/29/2022] [Accepted: 12/03/2022] [Indexed: 05/09/2023]
Abstract
OBJECTIVES Nadofaragene firadenovec is a gene therapy for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) undergoing Food and Drug Administration review. Pembrolizumab is approved for treating patients with BCG-unresponsive NMIBC with carcinoma in situ (CIS). We evaluated the cost-effectiveness of these treatments compared with a hypothetical therapeutic alternative, at a willingness-to-pay threshold of $150 000 per quality-adjusted life-year (QALY) gained, in CIS and non-CIS BCG-unresponsive NMIBC populations. METHODS We developed a Markov cohort simulation model with a 3-month cycle length and lifetime horizon to estimate the total costs, QALYs, and cost per additional QALY from the health sector perspective. Clinical inputs were informed by results of single-arm clinical trials evaluating the treatments, and systematic literature reviews were conducted to obtain other model inputs. Sensitivity analyses were conducted to assess uncertainty in model results. RESULTS Nadofaragene firadenovec, at a placeholder price 10% higher than the price of pembrolizumab, had an incremental cost-effectiveness ratio of $263 000 and $145 000 per QALY gained in CIS and non-CIS populations, respectively. Pembrolizumab had an incremental cost-effectiveness ratio of $168 000 per QALY gained for CIS. A 5.4% reduction in pembrolizumab's price would make it cost-effective. The model was sensitive to many inputs, especially to the probabilities of disease progression, initial treatment response and durability, and drug price. CONCLUSIONS The cost-effectiveness of nadofaragene firadenovec will depend upon its price. Pembrolizumab, although not cost-effective in our base-case analysis, is an important alternative in this population with an unmet medical need. Comparative trials of these treatments are warranted to better estimate cost-effectiveness.
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Affiliation(s)
- Mrinmayee Joshi
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA
| | - Steven J Atlas
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Molly Beinfeld
- Center for Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | | | - David M Rind
- Institute for Clinical and Economic Review, Boston, MA, USA
| | | | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois Chicago College of Pharmacy, Chicago, IL, USA.
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Kenigsberg AP, Carpinito G, Gold SA, Meng X, Ghoreifi A, Djaladat H, Minervini A, Jamil M, Abdollah F, Farrow JM, Sundaram C, Uzzo R, Ferro M, Meagher M, Derweesh I, Wu Z, Porter J, Katims A, Mehrazin R, Mottrie A, Simone G, Reese AC, Eun DD, Bhattu AS, Gonzalgo ML, Carbonara U, Autorino R, Margulis V. Practice trends for perioperative intravesical chemotherapy in upper tract urothelial carcinoma: Low but increasing utilization during minimally invasive nephroureterectomy. Urol Oncol 2022; 40:452.e17-452.e23. [DOI: 10.1016/j.urolonc.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/03/2022] [Accepted: 06/12/2022] [Indexed: 11/29/2022]
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15
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Cheng W, Zhou Y, Chu X, Huang S, Zheng X, Zheng H. Efecto de la mitomicina en comparación con la gemcitabina intravesical en el tratamiento del cáncer de vejiga sin invasión muscular: metaanálisis. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Ward K, Kitchen MO, Mathias SJ, Khanim FL, Bryan RT. Novel intravesical therapeutics in the treatment of non-muscle invasive bladder cancer: Horizon scanning. Front Surg 2022; 9:912438. [PMID: 35959122 PMCID: PMC9360612 DOI: 10.3389/fsurg.2022.912438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/07/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Non-muscle-invasive bladder cancer (NMIBC) is a common and heterogeneous disease; many patients develop recurrent or progress to muscle-invasive disease. Intravesical drug therapy is a pillar in the current management of NMIBC; notwithstanding, Mitomycin C (MMC) and Bacillus Calmette-Guérin (BCG) have numerous limitations including international supply issues, and local and systemic toxicity. Here we review novel intravesical therapeutic options and drug delivery devices with potential for clinical use in the treatment of NMIBC. Methods PubMed, ClinicalTrials.gov and Cochrane Library searches were undertaken. Systematic reviews, meta-analyses, randomised controlled trials, single-arm clinical trials and national/international conference proceedings were included. Results Novel intravesical drugs, including chemotherapeutic agents, immune checkpoint inhibitors, monoclonal antibodies and gene therapies, have demonstrated varying efficacy in the treatment of NMIBC. Current evidence for the majority of treatments is mostly limited to single-arm trials in patients with recurrent NMIBC. Various novel methods of drug delivery have also been investigated, with encouraging preliminary results supporting the intravesical delivery of hyperthermic MMC and MMC hydrogel formulations. Conclusions Novel therapeutic agents and drug delivery systems will be important in the future intravesical management of NMIBC. As our understanding of the molecular diversity of NMIBC develops, molecular subtyping will become fundamental in the personalisation of intravesical treatments. Further randomised studies are urgently required to investigate the efficacy of novel intravesical treatments and novel regimens, in comparison to current standards-of-care, particularly in the context of international BCG shortages.
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Affiliation(s)
- Kelly Ward
- The Bladder Cancer Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Mark O Kitchen
- School of Medicine, Keele University, Stoke-on-Trent, United Kingdom
| | - Suresh-Jay Mathias
- New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - Farhat L Khanim
- The Bladder Cancer Research Centre, University of Birmingham, Birmingham, United Kingdom
| | - Richard T Bryan
- The Bladder Cancer Research Centre, University of Birmingham, Birmingham, United Kingdom
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17
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Oral Preparation of Hyaluronic Acid, Chondroitin Sulfate, Curcumin, and Quercetin (Ialuril ® Soft Gels) for the Prevention of LUTS after Intravesical Chemotherapy. PATHOPHYSIOLOGY 2022; 29:365-373. [PMID: PMID: 35893598 PMCID: PMC9326532 DOI: 10.3390/pathophysiology29030028] [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: 06/12/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
Intravesical chemotherapy may cause chemical cystitis and related lower urinary tract symptoms (LUTS). The aims of this study were to evaluate the efficacy and safety of an oral preparation of hyaluronic acid (HA), chondroitin sulfate (CS), curcumin, and quercetin (Ialuril® Soft Gels) to reduce the severity of LUTS in patients with a history of bladder cancer (BCa) undergoing intravesical chemotherapy. We designed a monocentric, randomized, double-blind, placebo-controlled pilot trial. Patients referred to our institute between November 2016 and March 2018 were enrolled. All subjects had non-muscle-invasive BCa and received intravesical chemotherapy with mitomycin C (MMC). Patients were randomized 1:1 in two groups (intervention vs. control). All subjects underwent oral administration (Ialuril® Soft Gels or placebo) starting one week before the first weekly instillation and ending 30 days after the last one, subsequently starting one week before each monthly instillation and ending 14 days after it. International prostate symptom score (IPSS) and 0-100 visual analogue scale (VAS) were used to assess the efficacy of the treatment. Adverse events were also described. Patients were evaluated at baseline and after 1, 4, 7, and 13 months of intravesical chemotherapy. A total of 34 patients were enrolled. The median IPSS score was significantly lower in the intervention group compared to the control group at 4 (13 vs. 17 points; p = 0.038), 7 (10 vs. 18 points; p < 0.001), and 13 (10 vs. 17 points; p = 0.002) months. The median VAS score was significantly lower in the intervention group compared to the control group at 7 (22 vs. 37 points; p = 0.021) and 13 (20 vs. 35 points; p = 0.024) months. No AE specifically related to supplement or placebo was recorded. Oral formulation of HA, CS, quercetin, and curcumin could be an effective and safe supportive therapy against chemical cystitis in patients receiving intravesical chemotherapy for BCa.
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Koimtzis G, Alexandrou V, Chalklin CG, Carrington-Windo E, Ramsden M, Karakasis N, Lam KW, Tsakaldimis G. The Role of Adjuvant Single Postoperative Instillation of Gemcitabine for Non-Muscle-Invasive Bladder Cancer: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2022; 12:diagnostics12051154. [PMID: 35626309 PMCID: PMC9140686 DOI: 10.3390/diagnostics12051154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/05/2022] [Accepted: 04/29/2022] [Indexed: 02/05/2023] Open
Abstract
Bladder cancer is a heterogeneous disease with variable natural history. Non-muscle-invasive bladder cancer has a favorable prognosis following transurethral resection, but the optimal adjuvant chemotherapy plan is still in debate. The aim of this study was to evaluate the effect of the adjuvant intravesical administration of a single dose of gemcitabine in the outcome of this disease. For that purpose, we performed a systematic review and meta-analysis on available randomized control trials on MEDLINE, EMBASE, Cochrane, Scopus, and Google Scholar databases. Ultimately, two studies were included with a total number of 654 patients. The statistical analysis performed showed that a single post-operative intravesical dose of gemcitabine does not affect the recurrence rate of non-muscle-invasive bladder cancer compared to placebo. Therefore, this therapeutic strategy does not offer any significant improvement on the outcomes of the disease. Nonetheless, due to the plethora of available therapeutic agents and treatment strategies, further research is needed to establish the optimal treatment in this category of patients.
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Affiliation(s)
- Georgios Koimtzis
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK; (C.G.C.); (E.C.-W.); (M.R.); (K.W.L.)
- Correspondence: ; Tel.: +44-7716466710
| | - Vyron Alexandrou
- Urology Department, General Hospital of Thessaloniki “G. Gennimata-Agios Dimitrios”, Elenis Zografou 2, 546 34 Thessaloniki, Greece; (V.A.); (N.K.); (G.T.)
| | - Christopher G. Chalklin
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK; (C.G.C.); (E.C.-W.); (M.R.); (K.W.L.)
| | - Eliot Carrington-Windo
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK; (C.G.C.); (E.C.-W.); (M.R.); (K.W.L.)
| | - Mark Ramsden
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK; (C.G.C.); (E.C.-W.); (M.R.); (K.W.L.)
| | - Nikolaos Karakasis
- Urology Department, General Hospital of Thessaloniki “G. Gennimata-Agios Dimitrios”, Elenis Zografou 2, 546 34 Thessaloniki, Greece; (V.A.); (N.K.); (G.T.)
| | - Kit W. Lam
- Cardiff Transplant Unit, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff CF14 4XW, UK; (C.G.C.); (E.C.-W.); (M.R.); (K.W.L.)
| | - Georgios Tsakaldimis
- Urology Department, General Hospital of Thessaloniki “G. Gennimata-Agios Dimitrios”, Elenis Zografou 2, 546 34 Thessaloniki, Greece; (V.A.); (N.K.); (G.T.)
- Department of Medicine, Democritus University of Thrace, Administrative Building, 6th km, 681 00 Alexandroupoli, Greece
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19
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Gakis G. [Adjuvant instillation therapy for non-muscle invasive bladder cancer - beyond BCG and mitomycin C]. Aktuelle Urol 2022; 53:148-152. [PMID: 35172349 DOI: 10.1055/a-1677-0952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Due to limited local efficacy of BCG and mitomycin C and the worldwide shortage of BCG, there is a clinical need to develop novel intravesical agents and application forms in order to improve the oncological outcomes in non-muscle invasive bladder cancer (NMIBC). Gemcitabine has been investigated in various clinical trials. It has proven to be superior to BCG rechallenge and MMC in BCG-unresponsive high-risk NMIBC. GemRIS is an implantable novel form of intravesical drug delivery of gemcitabine and is currently being investigated with cetrelimab, a checkpoint inhibitor, in patients with high-risk NMIBC and MIBC. Hyperthermic intravesical chemotherapy (HIVEC) leads to increased concentrations of MMC in the bladder wall and is also being investigated in various NMIBC settings. Nadofaragene firadenovec (rAd-IFN-α/Syn3) is a recombinant adenovirus that induces release of interferon-alpha in the urothelium. In a randomised study on patients with BCG-unresponsive NMIBC, it has shown relatively superior efficacy and tolerability compared with studies evaluating the role of checkpoint inhibitor monotherapies. Opportuzumab monatox is a recombinant fusion protein which binds to EpCAM and induces release of exotoxins, resulting in cytotoxic cell death. N-803 is an interleukin (IL)-15 analogue, which has been investigated in a phase 1b study in combination with BCG and has shown durable complete response in all nine patients for 72 months. It was granted breakthrough designation status by the FDA in 2019.
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Affiliation(s)
- Georgios Gakis
- Department of Urology and Pediatric Urology, University Hospital of Würzburg, Würzburg, Germany
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20
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Adjuvant therapies for non-muscle-invasive bladder cancer: advances during BCG shortage. World J Urol 2022; 40:1111-1124. [PMID: 35083522 DOI: 10.1007/s00345-021-03908-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 12/07/2021] [Indexed: 02/07/2023] Open
Abstract
Non-muscle-invasive bladder cancer (NMIBC) represents a significant global therapeutic challenge, particularly in the era of Bacillus Calmette-Guérin (BCG) shortage. High-risk NMIBC can progress to muscle invasive or metastatic disease in 25% of patients. Optimal treatment selection, according to risk stratification, is imperative. International guidelines slightly differ in their categorisation of low, intermediate and high-risk NMIBC. Nonetheless, a single post-operative instillation of chemotherapy with Mitomycin C (MMC) or Gemcitabine improves relapse-free survival (RFS) in low-risk NMIBC. Induction and maintenance intravesical BCG remains the historical gold standard for patients with intermediate or high-risk NMIBC. However, clinicians may be forced to consider alternatives given the current BCG shortage. Both intravesical MMC and Gemcitabine have been associated with similar efficacy to BCG, albeit in smaller studies. MMC may also be manipulated using a variety of methods to potentiate its effects. BCG treatment delivery may also be modified without affecting efficacy through dose reduction and abbreviation or omission of maintenance therapy. Preliminary data also highlight that directly proceeding to radical cystectomy may not adversely affect long-term quality of life measures. Access to new systemic and intravesical therapies must be prioritised for patients with BCG recurrent or unresponsive disease. When used in conjunction with molecularly defined biomarkers, these agents herald the potential for improved survival outcomes and alleviation of the current BCG shortage.
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21
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Bellat V, Michel AO, Thomas C, Stokol T, Choi B, Law B. A urinary drug-disposing approach as an alternative to intravesical chemotherapy for treating non-muscle invasive bladder cancer. Cancer Res 2022; 82:1409-1422. [PMID: 35039320 DOI: 10.1158/0008-5472.can-21-2897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/22/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022]
Abstract
The standard treatment of non-muscle invasive bladder cancer (NMIBC) is transurethral resection of the tumors, followed by intravesical therapy (IT), which comprises a direct instillation of a solution of Bacillus Calmette-Guérin vaccine or chemotherapy into the bladder. However, the recurrence rate in this disease remains unacceptably high. IT is a local treatment that fails to reach tumors developed in the upper urinary tract (ureter and renal pelvis). The catheterization procedure required for IT is invasive, painful, and poses an increased infection risk resulting in poor patient quality of life and compliance. There is an unmet need for a potent, comprehensive, and non-invasive option. Without chemical modifications, peptides are rapidly removed by renal clearance. This "shortcoming" can be advantageous when used as a drug carrier for directing therapy to NMIBC. Here we develop a urinary drug-disposing (UDD) approach to improve NMIBC treatment. A 12-amino acid bio-inert peptide (Bdd) that can be exclusively eliminated via renal filtration was generated for delivering the microtubule inhibitor DM1 to NMIBC with minimal non-specific accumulation in other organs. The UDD approach prolonged survival of mice bearing human bladder tumors. Unlike IT, the treatment was given non-invasively (intravenously). Furthermore, it was more effective at suppressing tumor growth than clinically used IT (mitomycin) and safer than free DM1. The application of this urinary drug-disposing approach to treat kidney tumors and deliver other drugs such as doxorubicin was also demonstrated. Overall, the rapid renal clearance of peptides can be exploited to direct cancer therapies to the urinary system.
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Affiliation(s)
- Vanessa Bellat
- Molecular Imaging Innovations Institute, Department of Radiology, Weill Cornell Medicine
| | | | | | - Tracy Stokol
- Population Medicine and Diagnostic Sciences, Cornell University
| | | | - Benedict Law
- Molecular Imaging Innovations Institute, Department of Radiology, Weill Cornell Medicine
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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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Steinberg RL, Packiam VT, Thomas LJ, Brooks N, Vitale A, Mott SL, Crump T, Wang J, DeWolf WC, Lamm DL, Kates M, Hyndman ME, Kamat AM, Bivalacqua TJ, Nepple KG, O'Donnell MA. Intravesical sequential gemcitabine and docetaxel versus bacillus calmette-guerin (BCG) plus interferon in patients with recurrent non-muscle invasive bladder cancer following a single induction course of BCG. Urol Oncol 2022; 40:9.e1-9.e7. [PMID: 34092482 DOI: 10.1016/j.urolonc.2021.03.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Repeat BCG induction remains an option for select non-muscle invasive bladder cancer (NMIBC) patients who fail initial therapy. Alternative salvage intravesical regimens such as Gemcitabine and Docetaxel (Gem/Doce) have been investigated. We aimed to compare the efficacy BCG plus interferon a-2b (BCG/IFN) and Gem/Doce in patients with recurrent NMIBC after a single prior BCG course. METHODS The National Phase II BCG/IFN trial database and multi-institutional Gem/Doce database were queried for patients with recurrent NMIBC after one prior BCG induction course, excluding those with BCG unresponsive disease. Stabilized inverse probability treatment weighted survival curves were estimated using the Kaplan-Meier method and compared. Propensity scores were derived from a logistic regression model. The primary outcome was recurrence free survival (RFS); secondary outcomes were high-grade (HG) RFS and risk factors for treatment failure. RESULTS We identified 197 BCG/IFN and 93 Gem/Doce patients who met study criteria. Patients receiving Gem/Doce were older and more likely to have HG disease, CIS, and persistent disease following induction BCG (all P < 0.01). After propensity score-based weighting, the adjusted 1- and 2-year RFS was 61% and 53% after BCG/IFN versus 68% and 46% after Gem/Doce (P = 0.95). Adjusted 1- and 2-year HG-RFS was 60% and 51% after BCG/IFN versus 63% and 42% after Gem/Doce (P = 0.68). Multivariable Cox regression revealed that Gem/Doce treatment was not associated with an increased risk of failure (HR = 0.97, P = 0.89) as compared to BCG/IFN. CONCLUSION Patients with recurrent NMIBC after a single induction BCG failure and not deemed BCG unresponsive had similar oncologic outcomes with Gem/Doce and BCG/IFN in a post-hoc analysis. Additional prospective studies are needed.
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Affiliation(s)
| | | | - Lewis J Thomas
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Andrew Vitale
- Department of Urology, University of Iowa, Iowa City, IA
| | - Sarah L Mott
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Trafford Crump
- Department of Urology, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Donald L Lamm
- University of Arizona School of Medicine, Phoenix, Az; BCG Oncology, Phoenix, Az
| | - Max Kates
- Department of Urology, Johns Hopkins University, Baltimore, MD
| | - M Eric Hyndman
- Department of Urology, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Kenneth G Nepple
- Department of Urology, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | - Michael A O'Donnell
- Department of Urology, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA.
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Han MA, Maisch P, Jung JH, Hwang JE, Narayan V, Cleves A, Hwang EC, Dahm P. Intravesical gemcitabine for non-muscle invasive bladder cancer: An abridged Cochrane Review. Investig Clin Urol 2021; 62:623-630. [PMID: 34729962 PMCID: PMC8566788 DOI: 10.4111/icu.20210265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/23/2021] [Accepted: 09/06/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose To assess the comparative effectiveness and toxicity of intravesical gemcitabine instillation for non-muscle invasive bladder cancer (NMIBC). Materials and Methods We performed a comprehensive literature search on 11 September 2020. We included RCTs in which participants received intravesical gemcitabine for primary or recurrent NMIBC. Two review authors independently assessed the included studies and extracted data for the primary outcomes (time to recurrence, time to progression, grade III to V adverse events) and the secondary outcomes (time to death from bladder cancer, time to death from any cause, grade I or II adverse events, and disease-specific quality of life). We performed statistical analyses using a random-effects model and rated the certainty of the evidence using GRADE. Results We found seven studies with 1,222 participants. Gemcitabine may reduce the risk of recurrence over time, but may have a similar effect on progression and grade III to V adverse events compared to saline. Gemcitabine may reduce recurrence and progression compared to mitomycin. We are uncertain about the effect of gemcitabine on the grade III to V adverse events compared to mitomycin. Gemcitabine may reduce recurrence and progression compared to giving BCG again in recurrent high-risk NMIBC after BCG treatment. Conclusions Based on the findings of this review, gemcitabine may have a favorable impact on recurrence and progression-free survival than saline and mitomycin but we are uncertain about how major adverse events compare. The same is true when comparing gemcitabine to BCG in individuals with high-risk diseases who have previously failed BCG.
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Affiliation(s)
- Mi Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, Korea
| | - Philipp Maisch
- Department of Urology, Rechtsder Isar Medical Center, Technical University of Munich, Munich, Germany
| | - Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea.,Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea
| | - Jun Eul Hwang
- Department of Hematology-Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Vikram Narayan
- Department of Urology, Emory University, Atlanta, GA, USA
| | - Anne Cleves
- Velindre NHS Trust, Cardiff University Library Services, Cardiff, UK
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Medical School, Gwangju, Korea.
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN, USA.,Department of Urology, University of Minnesota, Minneapolis, MN, USA
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25
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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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26
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Slovacek H, Zhuo J, Taylor JM. Approaches to Non-Muscle-Invasive Bladder Cancer. Curr Oncol Rep 2021; 23:105. [PMID: 34269918 DOI: 10.1007/s11912-021-01091-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Non-muscle-invasive bladder cancer (NMIBC) is a heterogenous malignancy with high recurrence and progression rates, which necessitate uniform recommendations for diagnosis and management. Herein, we review the literature, with an emphasis on guidelines and contemporary diagnostic techniques and interventions. RECENT FINDINGS Guidelines around the world have adopted a schema which risk-stratify cases at diagnosis, to offer evidence-based treatment and surveillance recommendations. Enhanced endoscopic technologies can improve detection of NMIBC and reduce recurrence. The present Bacillus Calmette-Guerin (BCG) shortage in the USA has led to new strategies to prioritize the most high-risk cases. The entity of BCG-unresponsive high-risk NMIBC remains a challenge to manage, with multiple novel treatments under investigation; fortunately, new therapies have been approved, such as immune checkpoint inhibitors, and others are showing tremendous promise. The standardization of NMIBC management, with evolving detection techniques and therapeutics, offers great potential to improve patient outcomes and survivorship.
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Affiliation(s)
- Hannah Slovacek
- Loyola University Chicago Stritch School of Medicine, Chicago, IL, USA
| | - Jerry Zhuo
- Department of Urology, Baylor College of Medicine, 7200 Cambridge St, Ste 10B, Houston, TX, 77030, USA
| | - Jennifer M Taylor
- Department of Urology, Baylor College of Medicine, 7200 Cambridge St, Ste 10B, Houston, TX, 77030, USA.
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27
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Kuperus JM, Busman RD, Kuipers SK, Broekhuizen HT, Noyes SL, Brede CM, Tobert CM, Lane BR. Comparison of Side Effects and Tolerability Between Intravesical Bacillus Calmette-Guerin, Reduced-Dose BCG and Gemcitabine for Non-Muscle Invasive Bladder Cancer. Urology 2021; 156:191-198. [PMID: 34217763 DOI: 10.1016/j.urology.2021.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/28/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare patient-reported side effects and tolerability of full-dose Bacillus Calmette-Guérin (BCG), reduced-dose BCG, and gemcitabine one week after administration. METHODS All patients from July 2019 to November 2020 receiving intravesical therapy (IVT) for non-muscle invasive bladder cancer (NMIBC) at our institution were surveyed before repeat instillation. Survey questions recorded IVT retention times and the duration and severity of the following side effects: bladder symptoms, fatigue, body aches, hematuria, fever, chills, and other. All responses were collected and quantified in a de-identified, password-protected database. Statistical analysis was performed using SAS JMP 13. RESULTS Of 592 surveys completed, symptoms of any kind were reported on 463 surveys (78%) with the most common symptoms including bladder symptoms (59%), fatigue (52%), body aches (26%), and hematuria (18%). Patients were able to hold full-dose BCG, reduced-dose BCG, and gemcitabine for the protocol-specified duration 87%, 95%, and 71% of the time (P <0.05). The prevalence, severity, and duration of body aches were highest with gemcitabine (P <0.05) while the prevalence and duration of hematuria were higher with BCG (P <0.05). Reduced-dose BCG had the lowest prevalence, severity, and duration of fatigue (P <0.05). CONCLUSION Significant differences in the side effects and tolerability of full-dose BCG, reduced-dose BCG, and gemcitabine were demonstrated using this novel survey, and these differences are of value for informing IVT selection. Evaluation of IVTs other than gemcitabine and BCG will further inform selection of therapies for NMIBC.
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Affiliation(s)
| | - Ross D Busman
- Spectrum Health Hospital System, Grand Rapids, MI, 49503
| | | | | | | | - Christopher M Brede
- Spectrum Health Hospital System, Grand Rapids, MI, 49503; Michigan State University College of Human Medicine, East Lansing, MI, 48824
| | - Conrad M Tobert
- Spectrum Health Hospital System, Grand Rapids, MI, 49503; Michigan State University College of Human Medicine, East Lansing, MI, 48824
| | - Brian R Lane
- Spectrum Health Hospital System, Grand Rapids, MI, 49503; Michigan State University College of Human Medicine, East Lansing, MI, 48824.
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28
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Han MA, Maisch P, Jung JH, Hwang JE, Narayan V, Cleves A, Hwang EC, Dahm P. Intravesical gemcitabine for non-muscle invasive bladder cancer. Cochrane Database Syst Rev 2021; 6:CD009294. [PMID: 34125951 PMCID: PMC8202966 DOI: 10.1002/14651858.cd009294.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND It remains unclear whether people with non-muscle invasive bladder cancer (NMIBC) benefit from intravesical gemcitabine compared to other agents in the primary or recurrent setting following transurethral resection of a bladder tumor. This is an update of a Cochrane Review first published in 2012. Since that time, several randomized controlled trials (RCTs) have been reported, making this update relevant. OBJECTIVES: To assess the comparative effectiveness and toxicity of intravesical gemcitabine instillation for NMIBC. SEARCH METHODS We performed a comprehensive literature search of the Cochrane Library, MEDLINE, Embase, four other databases, trial registries, and conference proceedings to 11 September 2020, with no restrictions on the language or status of publication. SELECTION CRITERIA We included RCTs in which participants received intravesical gemcitabine for primary or recurrent NMIBC. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the included studies and extracted data for the primary outcomes: time to recurrence, time to progression, grade III to V adverse events determined by the Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0), and the secondary outcomes: time to death from bladder cancer, time to death from any cause, grade I or II adverse events determined by the CTCAE v5.0 and disease-specific quality of life. We performed statistical analyses using a random-effects model and rated the certainty of the evidence using GRADE. MAIN RESULTS We included seven studies with 1222 participants with NMIBC across five comparisons. This abstract focuses on the primary outcomes of the three most clinically relevant comparisons. 1. Gemcitabine versus saline: based on two years' to four years' follow-up, gemcitabine may reduce the risk of recurrence over time compared to saline (39% versus 47% recurrence rate, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.54 to 1.09; studies = 2, participants = 734; I2 = 49%; low-certainty evidence), but the CI included the possibility of no effect. Gemcitabine may result in little to no difference in the risk of progression over time compared to saline (4.6% versus 4.8% progression rate, HR 0.96, 95% CI 0.19 to 4.71; studies = 2, participants = 654; I2 = 53%; low-certainty evidence). Gemcitabine may result in little to no difference in the CTCAE grade III to V adverse events compared to saline (5.9% versus 4.7% adverse events rate, risk ratio [RR] 1.26, 95% CI 0.58 to 2.75; studies = 2, participants = 668; I2 = 24%; low-certainty evidence). 2. Gemcitabine versus mitomycin: based on three years' follow-up (studies = 1, participants = 109), gemcitabine may reduce the risk of recurrence over time compared to mitomycin (17% versus 40% recurrence rate, HR 0.36, 95% CI 0.19 to 0.69; low-certainty evidence). Gemcitabine may reduce the risk of progression over time compared to mitomycin (11% versus 18% progression rate, HR 0.57, 95% CI 0.32 to 1.01; low-certainty evidence), but the CI included the possibility of no effect. We are very uncertain about the effect of gemcitabine on the CTCAE grade III to V adverse events compared to mitomycin (RR 0.51, 95% CI 0.13 to 1.93; very low-certainty evidence). The analysis was only based on recurrent NMIBC. 3. Gemcitabine versus Bacillus Calmette-Guérin (BCG) for recurrent (one-course BCG failure) high-risk NMIBC: based on 6 months' to 22 months' follow-up (studies = 1, participants = 80), gemcitabine may reduce the risk of recurrence compared to BCG (41% versus 97% recurrence rate, HR 0.15, 95% CI 0.09 to 0.26; low-certainty evidence) and progression over time (16% versus 33% progression rate, HR 0.45, 95% CI 0.27 to 0.76; low-certainty evidence). We are very uncertain about the effect of gemcitabine on the CTCAE grade III to V adverse events compared to BCG (RR 1.00, 95% CI 0.21 to 4.66; very low-certainty evidence). In addition, the review provides information on the comparison of gemcitabine versus BCG and gemcitabine versus one-third dose BCG. AUTHORS' CONCLUSIONS: Based on findings of this review, gemcitabine may have a more favorable impact on recurrence and progression-free survival than mitomycin but we are very uncertain as to how major adverse events compare. The same is true when comparing gemcitabine to BCG in individuals with high risk disease who have previously failed BCG. The underlying low- to very low-certainty evidence indicates that our confidence in these results is limited; the true effects may be substantially different from these findings; therefore, better quality studies are needed.
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Affiliation(s)
- Mi Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, Korea, South
| | - Philipp Maisch
- Department of Urology, Rechts der Isar Medical Center, Technical University of Munich, Munich, Germany
| | - Jae Hung Jung
- Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Korea, South
- Center of Evidence Based Medicine, Institute of Convergence Science, Yonsei University, Seoul, Korea, South
| | - Jun Eul Hwang
- Department of Hematology-Oncology, Chonnam National University Medical School, Chonnam National University Hwasun Hospital, Hwasun, Korea, South
| | - Vikram Narayan
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anne Cleves
- Velindre NHS Trust, Cardiff University Library Services, Cardiff, UK
| | - Eu Chang Hwang
- Department of Urology, Chonnam National University Medical School, Chonnam National University Hwasun Hospital, Hwasun, Korea, South
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
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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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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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31
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Matzen M, Offermann A, Tharun L, Perner S, Merseburger AS, Kramer M, Hupe MC. [Intravesical Gemcitabine instillations following BCG failure and allergy to Mitomycin: A unique case of a patient with an inverted papilloma of the bladder]. Aktuelle Urol 2021; 52:43-46. [PMID: 33525029 DOI: 10.1055/a-1312-9032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Intravesical chemotherapy instillation is a unique method of treatment confined to urothelial neoplasia. Within the last decades, the substances Bacillus Calmette-Guerin (BCG) and mitomycin C (MMC) have evolved as the standard regimens for intravesical therapy. However, there are other chemotherapeutic substances, which are used less frequently, such as gemcitabine. In this article we aim to highlight the clinical relevance of intravesical gemcitabine instillations as treatment of non-muscle invasive bladder cancer.The histological subtypes of bladder tumours are as diverse as the intravesical regimens. Inverted papilloma is a rare entity in the spectrum of urological diseases. There seems to be an association with non-muscle invasive bladder cancer.We report a rare case of an inverted bladder papilloma treated with intravesical gemcitabine instillations after BCG failure and an allergic reaction to MMC.
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Affiliation(s)
- Merle Matzen
- University Hospital Schleswig-Holstein, Campus Luebeck, Department of Urology, Luebeck
| | - Anne Offermann
- University Hospital Schleswig-Holstein, Campus Luebeck, Institute of Pathology, Luebeck
| | - Lars Tharun
- University Hospital Schleswig-Holstein, Campus Luebeck, Institute of Pathology, Luebeck
| | - Sven Perner
- University Hospital Schleswig-Holstein, Campus Luebeck, Institute of Pathology, Luebeck
- Research Center Borstel, Leibniz Lung Center, Pathology, Borstel
| | - Axel S. Merseburger
- University Hospital Schleswig-Holstein, Campus Luebeck, Department of Urology, Luebeck
| | - Mario Kramer
- University Hospital Schleswig-Holstein, Campus Luebeck, Department of Urology, Luebeck
| | - Marie Christine Hupe
- University Hospital Schleswig-Holstein, Campus Luebeck, Department of Urology, Luebeck
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32
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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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Intravesical Salvage Therapy After BCG/Regular Chemo. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_12] [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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34
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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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35
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Sharma V, Thakur APS, Ramasamy V, Shukla PK, Solanki FS, Choudhary A, Patel P. Complications of intravesical BCG therapy in non-muscle invasive bladder cancer: our tertiary care centre experience. AFRICAN JOURNAL OF UROLOGY 2020. [DOI: 10.1186/s12301-020-00099-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Abstract
Background
Urothelial bladder carcinoma accounts for around 3.9% cases of all the male cancers in India. Non-muscle-invasive bladder carcinoma (NMIBC) is predominant group which constitute approximately three fourth of the urothelial bladder cancer. Intravesical BCG immunotherapy is the corner stone of today’s NMIBC management. However, as with any other therapy it has its own complications and its interruption due to these adverse effects is a major cause of suboptimal efficacy. The aim of this study was to assess the complications of intravesical BCG therapy and their management in NMIBC patients.
Methods
This was a retrospective descriptive study conducted between October 2016 and November 2019; a backward review of 149 patients with diagnosis of NMIBC that undergone intravesicle BCG therapy was performed. Patient’s demographical, clinical, diagnostic and procedural data regarding bladder tumour, BCG therapy, its complications and management were collected and analysed.
Results
Total 149 patients were analysed, comprising 116 males and 33 females. The mean age was of 57.2 ± 6.7 years. Total 85.23% were primary and 14.76% were recurrent tumours. Total 96 patients (64.42%) completed the planned course, while 53 (35.57%) interrupted. The reasons for BCG interruption includes adverse effects (15.4%), progression of disease (6.7%), disease refractory to BCG (4.6%) and disease recurrence during BCG (3.3%). Most of the adverse events occurred in first 6 months and most interruptions occurred after the induction period. Cystitis was the most common observed adverse effect seen in 39.6% patients. Frequency, urgency, haematuria were common presentation. Radical cystectomy was the most common (16.10%) further treatment with patients whose treatment was interrupted.
Conclusion
BCG is an indispensable therapy available for NMIBC, but it is associated with array of adverse effects and complications, which are the main reasons for poor compliance to BCG therapy. Although BCG-related complications can affect any organ in the body, potentially life-threatening systemic BCG-related infections are encountered in only < 5% of patients. There are some difficulties in diagnosis of the BCG complications because acid-fast staining, culture and PCR test are not always positive; tissue biopsies should be indicated sometimes to evaluate histopathology and presence of M. bovis. A persistently monitored multidisciplinary approach with high index of suspicion and prompt anti-TB therapy can help to derive the maximum benefits while keeping the complications at check.
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A polymeric paste-drug formulation for local treatment of upper tract urothelial carcinoma. Urol Oncol 2020; 39:194.e1-194.e7. [PMID: 33250343 DOI: 10.1016/j.urolonc.2020.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/13/2020] [Accepted: 07/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intravesical instillation of chemo- or immunotherapy is commonly used in bladder cancer. Upper tract urothelial carcinoma (UTUC) shares similar pathological features, but current formulations are not suitable for direct instillation to the upper urinary tract. OBJECTIVE To evaluate in vivo applicability, characteristics and toxicity of ST-UC, a mucoadhesive polymeric paste formulation of gemcitabine, for upper urinary tract instillation. MATERIAL AND METHODS Three pigs received 10 ml of ST-UC (100 mg/ml gemcitabine) retrogradely into 1 renal pelvis for pharmacokinetic studies. Four days later, a second injection into the contralateral renal pelvis was followed by serial euthanasia of the pigs and nephroureterectomy after 1, 3, and 6 hours. Adverse effects were monitored. Urine, serum, and tissue gemcitabine concentrations were measured, along with histologic examination of the upper urinary tract. RESULTS Retrograde instillation of ST-UC was well tolerated with mild, completely receding hydronephrosis. Urine gemcitabine concentrations were highest in the first 3-hour collection interval. Hundred percent of gemcitabine was recovered in the urine within 24 hours. Serum peak concentrations (cmax) of gemcitabine were low at 5.5 µg/ml compared to the 10 to 30 µg/ml levels observed after a single intravenous dose of 1,000 mg/m2 gemcitabine. The formulation was still traceable after one hour and gemcitabine tissue concentrations are supportive of this extended drug exposure. No major histopathological changes were observed. The main limitation of this study is the lack of antitumor activity data. CONCLUSION This preclinical evaluation of ST-UC demonstrated feasible instillation in the renal pelvis, no significant safety concerns, and sustained release of gemcitabine.
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Koch GE, Smelser WW, Chang SS. Side Effects of Intravesical BCG and Chemotherapy for Bladder Cancer: What They Are and How to Manage Them. Urology 2020; 149:11-20. [PMID: 33181123 DOI: 10.1016/j.urology.2020.10.039] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 10/25/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
Intravesical therapy for nonmuscle invasive bladder cancer decreases recurrence and progression but carries a high risk of side effects, which limit patient adherence. Appropriate management of the toxicities from intravesical therapy requires consideration of the agent used, the side effects experienced, and the timing of those side effects. Management strategies for intravesical toxicities ideally improve patient tolerance without sacrificing oncologic outcomes. This review aims to provide a comprehensive overview of the available evidence regarding the side effects of intravesical therapies for nonmuscle invasive bladder cancer and to propose practical strategies for toxicity management.
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Affiliation(s)
- George E Koch
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Woodson W Smelser
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Sam S Chang
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN.
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Hurle R, Contieri R, Casale P, Morenghi E, Saita A, Buffi N, Lughezzani G, Colombo P, Frego N, Fasulo V, Paciotti M, Guazzoni G, Lazzeri M. Midterm follow-up (3 years) confirms and extends short-term results of intravesical gemcitabine as bladder-preserving treatment for non-muscle-invasive bladder cancer after BCG failure. Urol Oncol 2020; 39:195.e7-195.e13. [PMID: 33268275 DOI: 10.1016/j.urolonc.2020.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/23/2020] [Accepted: 09/19/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND There is a high demand for bladder sparing therapies in patients who do not respond to bacillus Calmette-Guérin (BCG). OBJECTIVE To report the mid-term results of intravesical gemcitabine in non-muscle-invasive bladder cancer (NMIBC) patients, who failed BCG and who were unwilling to undergo radical cystectomy (RC). MATERIAL & METHODS This is an extended confirmatory open-label, single-arm study, which enrolled consecutive patients who failed BCG or were BCG intolerant and unwilling to undergo the RC (histologically confirmed Tis (CIS), T1 high grade or multifocal Ta high grade of the urinary bladder). Intravesical gemcitabine was administered once a week for 6 consecutive weeks and once a month for 12 months. The primary outcome was disease-free survival (DFS) defined as the lack of tumor on cystoscopy and negative urine cytology. The secondary endpoint was safety, defined according a grading of side effects. overall survival, progression-free survival and DFS were described with Kaplan-Meier method at 12, 24, and 36 months. RESULTS AND LIMITATIONS Overall 46 patients were enrolled. The mean follow-up was 40 months. The DFS was 69.05% at the end of induction phase and 32.69% at 36 months. The progression-free survival at 36 months was 65.38%. The overall survival and cancer specific survival were 66.97% (95% confidence interval 47.25%-80.70%) and 78.71% (95% confidence interval 59.16%-89.66%), 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 (lower urinary tract symptoms) and fatigue (G1-G2). CONCLUSION Intravesical gemcitabine seemed to represent a valid and safe alternative at 3 years follow-up for patients who failed BCG and were unwilling to undergo RC.
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Affiliation(s)
- Rodolfo Hurle
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Roberto Contieri
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Paolo Casale
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Emanuela Morenghi
- Department of Medical Statistic, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Alberto Saita
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Nicolòmaria Buffi
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy; Department of Medical Statistic, Humanitas Clinical and Research Center - IRCCS, Milan, Italy; Department of Urology, Department of Biomedical Sciences, Pieve Emanuele - Milano, Italy
| | - Giovanni Lughezzani
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy; Department of Urology, Department of Biomedical Sciences, Pieve Emanuele - Milano, Italy
| | - Piergiuseppe Colombo
- Department of Pathology, Humanitas Clinical and Research Center - IRCCS, (Milan), Italy
| | - Nicola Frego
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Vittorio Fasulo
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Marco Paciotti
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy
| | - Giorgio Guazzoni
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy; Department of Urology, Department of Biomedical Sciences, Pieve Emanuele - Milano, Italy
| | - Massimo Lazzeri
- Department of Urology, Humanitas Clinical and Research Center - IRCCS, Milan, Italy.
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Alshyarba MH, Alamri A, Assiri AA. Economic impacts of the Bacillus Calmette-Guérin (BCG) therapy shortage and the proposed solutions for patients with non-muscle invasive bladder Cancer in Aseer Province, Saudi Arabia. J Family Med Prim Care 2020; 9:2758-2762. [PMID: 32984121 PMCID: PMC7491787 DOI: 10.4103/jfmpc.jfmpc_171_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/13/2020] [Accepted: 03/30/2020] [Indexed: 11/04/2022] Open
Abstract
Objective To report the magnitude, the financial and the economic impact of Bacillus Calmette-Guérin (BCG) shortage in our institute and transfer of non-muscle invasive bladder cancer (NMIBC) patients to higher centers to receive the treatment. Methods This is a retrospective study, between January 2015 and December 2017, the cases of NMIBC diagnosed at Aseer Central Hospital, Abha, Saudi Arabia were studied. Demographic features, clinical presentations, histopathological features, and the BCG therapy shortage and its economic impact were addressed. Results Over a three years study review of 62 urothelial bladder cancer, NMIBC was diagnosed in 55 (89%) patients. Forty-three (78%) patients were males and 12 (22%) patients were females. The mean age ± standard deviation (SD) (range) in this cohort was 59 ± 12 years (38-87). Gross hematuria was the main presentation in 51 (92%) patients of this cohort. Dysuria and other lower urinary tract symptoms were the presentations in 18 (32%) patients. Smoking history was positive in 33 (60%) patients and the rest 22 (40%) patients denied any form of tobacco consumptions. The BCG eligible were 46 (84%) patients of all NMIBC patients in this study. Twenty-seven (59%) patients of them received BCG in our institute. The rest 19 (41%) patients were opted to be transferred to a higher medical center to receive the BCG because of the BCG shortage in our center. The financial cost of traveling to receive the six-weeks induction BCG therapy was on average of 7200 Saudi riyals (1.745 €) for every patient. Conclusions The BCG shortage in our institute is almost approaching half of eligible BCG cases. This has had an economic impact on the health budget. Such health catastrophe could be mitigated with proper health plans of a provision of the BCG to all tertiary care centers. Alternative therapies for such cases should be considered in cases of global BCG shortage.
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Affiliation(s)
- Mishari Hm Alshyarba
- Department of Surgery (Urology Division), College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Kingdom of Saud Arabia
| | - Abdulaziz Alamri
- Department of Surgery (Urology Division), College of Medicine, King Khalid University, P.O. Box 641, Abha 61421, Kingdom of Saud Arabia
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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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Li R, Li Y, Song J, Gao K, Chen K, Yang X, Ding Y, Ma X, Wang Y, Li W, Wang Y, Wang Z, Dong Z. Intravesical gemcitabine versus mitomycin for non-muscle invasive bladder cancer: a systematic review and meta-analysis of randomized controlled trial. BMC Urol 2020; 20:97. [PMID: 32660456 PMCID: PMC7358190 DOI: 10.1186/s12894-020-00610-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 04/06/2020] [Indexed: 01/09/2023] Open
Abstract
Background Mitomycin (MMC) has been frequently used as the compound for intravesical treatment. The relatively new pyrimidine analog gemcitabine (GEM) has exhibited anticancer effect on various solid cancers, such as the advanced bladder cancer. In this study, the GEM and MMC in treating non-muscle invasive bladder cancer (NMIBC) cases was compared through systemic review. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, the electronic databases, including Embase, PubMed, Chinese biomedicine literature database, the Cochrane Library, the National Institute for Health and Clinical Excellence, NHS Evidence, Chinese technological periodical full-text database, and Chinese periodical full-text database, were systemically reviewed from inception to October 2018. Then, the RevMan 5.0 software was applied for data analysis. Five randomized controlled trials (RCTs) involving a total of 335 patients were included. Results For MMC group, the recurrence rate in the mitomycin arm increased compared with that in GEM group (OR = 0.44 95% CI [0.24, 0.78]), and the difference was statistically significant between the two groups. GEM was associated with reduced incidence of chemical cystitis compared with that of MMC (OR = 0.23 95% CI [0.12, 0.44]). Differences in hematuria (OR = 0.46 95% CI [0.16, 1.31]), skin reaction (OR = 0.49 95% CI [0.14, 1.70]) and liver and kidney function damage (OR = 0.51 95% CI [0.09, 2.85]) displayed no statistical significance between the two groups. Conclusion Findings in our study demonstrate the superior efficacy of GEM over MMC in reducing the relapse rate among NMIBC patients following transurethral resection (TUR). In addition, GEM is associated with reduced local toxic effects on the bladder compared with those of MMC. However, more future studies are needed to examine GEM safety when used as the monotherapy or polytherapy for bladder patients. More RCTs with high quality are also required to validate our findings due to the limitations of the current meta-analysis.
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Affiliation(s)
- Rongxin Li
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Ye Li
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Jun Song
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China.,Sanya People's Hospital, Sanya City, Hainan Province, China
| | - Ke Gao
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Kangning Chen
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Xiaogang Yang
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Yongqiang Ding
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Xinlong Ma
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Yang Wang
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Weipeng Li
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Yanan Wang
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Zhiping Wang
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China
| | - Zhilong Dong
- Lanzhou University Second Hospital, Lanzhou City, Gansu Province, China.
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Freifeld Y, Ghandour R, Singla N, Woldu S, Bagrodia A, Lotan Y, Rapoport LM, Gazimiev M, Delafuente K, Kulangara R, Robyak H, Petros FG, Raman JD, Matin SF, Margulis V. Intraoperative prophylactic intravesical chemotherapy to reduce bladder recurrence following radical nephroureterectomy. Urol Oncol 2020; 38:737.e11-737.e16. [PMID: 32641241 DOI: 10.1016/j.urolonc.2020.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE Single, postoperative instillation of prophylactic intravesical chemotherapy (pIVC) is effective in reducing bladder cancer recurrences following radical nephroureterectomy (RNU). Despite high level evidence, pIVC is underutilized. Intraoperative pIVC (I-pIVC) may be easier and safer to implement than postoperative pIVC (P-pIVC). We aimed to evaluate the efficacy of I-pIVC during RNU. MATERIALS AND METHODS Retrospective analysis of patients undergoing RNU and I-pIVC or postoperative pIVC (P-pVC) with 20 to 40 mg mitomycin-C or 1 to 2 g gemcitabine. Recurrence rates were evaluated using the Kaplan-Meier curves and log rank test. Cox regression was used for univariable and multivariable analysis. RESULTS One hundred and thirty-seven patients were included in the final analysis. 81% (111/137) had I-pIVC and 19% (26/137) had P-pIVC. In the I-pIVC group higher rates of HG, muscle invasive disease and gemcitabine use were observed. Overall, 74% (101/137) and 26% (36/137) had mitomycin-C and gemcitabine instillations, respectively. Within 12 months 14% (19/137) of the patients experienced bladder recurrence. Median time to bladder recurrence was 7 months (range 3-27). Twelve months bladder recurrence-free survival rates were 82% for the I-pIVC group, and 72% for the P-pIVC group ((log rank P = 0.365). CONCLUSIONS I-pIVC during RNU may reduce bladder recurrence rates. Bladder recurrence rates are comparable to those reported using postoperative instillations. Intraoperative instillations may be easier to implement and may increase usage rates.
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Affiliation(s)
- Yuval Freifeld
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Rashed Ghandour
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nirmish Singla
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Solomon Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Aditya Bagrodia
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Leonid M Rapoport
- Research institute of Uronephrology and Human Reproductive Health, I.M Sechenov First Moscow State Medical University, Moscow, Russia
| | - Magomet Gazimiev
- Research institute of Uronephrology and Human Reproductive Health, I.M Sechenov First Moscow State Medical University, Moscow, Russia
| | - Karen Delafuente
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Haley Robyak
- Division of Urology, Penn State Health, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Firas G Petros
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jay D Raman
- Division of Urology, Penn State Health, Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Surena F Matin
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Vitaly Margulis
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX; Research institute of Uronephrology and Human Reproductive Health, I.M Sechenov First Moscow State Medical University, Moscow, Russia.
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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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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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Parapelvic Dystrophic Calcification as a Result of Mitomycin C Extravasation. Urology 2020; 136:e34-e36. [DOI: 10.1016/j.urology.2019.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/04/2019] [Accepted: 09/10/2019] [Indexed: 11/17/2022]
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Chehroudi AC, Black PC. Emerging intravesical therapies for the management of bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer: Charting a path forward. Can Urol Assoc J 2020; 14:204-213. [PMID: 31977307 DOI: 10.5489/cuaj.6101] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Management of patients with bacillus Calmette-Guérin (BCG)-unresponsive, high-risk, non-muscle-invasive bladder cancer (NMIBC) presents a formidable clinical challenge that requires urologists to weigh the competing risks of progression during further intravesical therapy vs. the morbidity of radical cystectomy. The prognosis of high-risk NMIBC recurring after BCG depends on the adequacy of prior BCG, timing of recurrence, and tumor histology. The standard of care is currently radical cystectomy, as effective salvage intravesical therapy has not been established. The development of bladder-sparing treatments has been hampered to date by inconsistent definitions of BCG failure and difficulties in identifying appropriate control treatments in clinical trials. Despite these limitations, the spectrum of salvage therapy is expanding to include enhanced intravesical chemo-, gene, and immuno-therapies. In this review, we provide an overview of these emerging agents in the context of our current understanding of BCG failure and the unique considerations for clinical trial design in this disease state.
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Affiliation(s)
- Ali Cyrus Chehroudi
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
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Khaled D, Taylor J, Holzbeierlein J. Salvage Therapy for Non-muscle-invasive Bladder Cancer: Novel Intravesical Agents. Urol Clin North Am 2019; 47:119-128. [PMID: 31757295 DOI: 10.1016/j.ucl.2019.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Bacillus Calmette-Guerin (BCG)-refractory high-grade non-muscle-invasive bladder cancer remains a challenging problem. Radical cystectomy is standard of care, but carries significant morbidity. Therefore, there is a need for effective treatments. Previous salvage intravesical therapies have had disappointing results with long-term follow-up; however, a wide array of novel agents is currently under investigation. These include novel combinations of existing intravesical agents, novel modes of delivery such as hyperthermia, viral mediated therapies, and immunotherapy. We review the need for novel treatment with existing agents and their long-term results, and discuss novel intravesical therapies and the data currently available on these therapies.
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Affiliation(s)
- Dunia Khaled
- Department of Urology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 3016, Kansas City, KS 66160, USA
| | - John Taylor
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jeffrey Holzbeierlein
- Department of Urology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 3016, Kansas City, KS 66160, USA.
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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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Annels NE, Mansfield D, Arif M, Ballesteros-Merino C, Simpson GR, Denyer M, Sandhu SS, Melcher AA, Harrington KJ, Davies B, Au G, Grose M, Bagwan I, Fox B, Vile R, Mostafid H, Shafren D, Pandha HS. Phase I Trial of an ICAM-1-Targeted Immunotherapeutic-Coxsackievirus A21 (CVA21) as an Oncolytic Agent Against Non Muscle-Invasive Bladder Cancer. Clin Cancer Res 2019; 25:5818-5831. [PMID: 31273010 DOI: 10.1158/1078-0432.ccr-18-4022] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/06/2019] [Accepted: 06/27/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE The CANON [CAVATAK in NON-muscle-invasive bladder cancer (NMIBC)] study evaluated a novel ICAM-1-targeted immunotherapeutic-coxsackievirus A21 as a novel oncolytic agent against bladder cancer. PATIENTS AND METHODS Fifteen patients enrolled in this "window of opportunity" phase I study, exposing primary bladder cancers to CAVATAK prior to surgery. The first 9 patients received intravesical administration of monotherapy CAVATAK; in the second stage, 6 patients received CAVATAK with a subtherapeutic dose of mitomycin C, known to enhance expression of ICAM-1 on bladder cancer cells. The primary endpoint was to determine patient safety and maximum tolerated dose (MTD). Secondary endpoints were evidence of viral replication, induction of inflammatory cytokines, antitumor activity, and viral-induced changes in resected tissue. RESULTS Clinical activity of CAVATAK was demonstrated by induction of tumor inflammation and hemorrhage following either single or multiple administrations of CAVATAK in multiple patients, and a complete resolution of tumor in 1 patient. Whether used alone or in combination with mitomycin C, CAVATAK caused marked inflammatory changes within NMIBC tissue biopsies by upregulating IFN-inducible genes, including both immune checkpoint inhibitory genes (PD-L1 and LAG3) and Th1-associated chemokines, as well as the induction of the innate activator RIG-I, compared with bladder cancer tissue from untreated patients. No significant toxicities were reported in any patient, from either virus or combination therapy. CONCLUSIONS The acceptable safety profile of CAVATAK, proof of viral targeting, replication, and tumor cell death together with the virus-mediated increases in "immunological heat" within the tumor microenvironment all indicate that CAVATAK may be potentially considered as a novel therapeutic for NMIBC.
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Affiliation(s)
- Nicola E Annels
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - David Mansfield
- Targeted Therapy Group, Institute of Cancer Research, London, United Kingdom
| | - Mehreen Arif
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | | | - Guy R Simpson
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Mick Denyer
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Sarbjinder S Sandhu
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, Surrey, United Kingdom
| | - Alan A Melcher
- Targeted Therapy Group, Institute of Cancer Research, London, United Kingdom
| | - Kevin J Harrington
- Targeted Therapy Group, Institute of Cancer Research, London, United Kingdom
| | | | | | | | - Izhar Bagwan
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Bernard Fox
- Robert W. Franz Cancer Research Center, Earle A. Chiles Research Institute, Portland, Oregon
| | | | - Hugh Mostafid
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | | | - Hardev S Pandha
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom.
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50
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Abstract
Non-muscle-invasive bladder cancer (NMIBC), the most prevalent type of bladder cancer, accounts for ~75% of bladder cancer diagnoses. This disease has a 50% risk of recurrence and 20% risk of progression within 5 years, despite the use of intravesical adjuvant treatments (such as BCG or mitomycin C) that are recommended by clinical guidelines. Intravesical device-assisted therapies, such as radiofrequency-induced thermochemotherapeutic effect (RITE), conductive hyperthermic chemotherapy, and electromotive drug administration (EMDA), have shown promising efficacy. These device-assisted treatments are an attractive alternative to BCG, as issues with supply have been a problem in some countries. RITE might be an effective treatment option for some patients who have experienced BCG failure and are not candidates for radical cystectomy. Data from trials using EMDA suggest that it is effective in high-risk disease but requires further validation, and results of randomized trials are eagerly awaited for conductive hyperthermic chemotherapy. Considerable heterogeneity in patient cohorts, treatment sessions, use of maintenance regimens, and single-arm study design makes it difficult to draw solid conclusions, although randomized controlled trials have been reported for RITE and EMDA.
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