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Holmsten K, Eknert J, Öfverholm E, Papantoniou D, Jawdat F, Verbiéné I, Laurell A, Jänes E, Sandzén J, Wojtyna-Dziedzic E, Lagstam I, Söderkvist K, Costa Svedman F, Liedberg F, Bruzelius M, Fransson AS, Kjellström S, Omland LH, Pappot H, Ullén A. Treatment Patterns and Efficacy of Chemotherapy After Pembrolizumab in Advanced Urothelial Cancer-a Real-World Study in the pre-Antibody-Drug Conjugate Era. Clin Genitourin Cancer 2023; 21:e438-e448. [PMID: 37308329 DOI: 10.1016/j.clgc.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have been established as a routine treatment in patients with metastatic urothelial cancer (mUC). However, there has been no standard of care after progression on ICIs. We investigated real-world treatment patterns and efficacy of chemotherapy (CHT) after pembrolizumab, in the era before introduction of maintenance avelumab and antibody-drug conjugates (ADC). PATIENTS AND METHODS An observational, retrospective study was conducted at twelve Nordic centers. Patients with mUC were treated according to investigator´s choice of CHT after pembrolizumab. Primary endpoint was overall response (ORR) and disease control rate (DCR); secondary endpoints were progression-free (PFS) and overall survival (OS). RESULTS In total, 102 patients were included whereof 23 patients received CHT after pembrolizumab as second line treatment (subcohort A) and 79 patients in third line (subcohort B). Platinum-gemcitabine combinations were the most common regimens in subcohort A, and vinflunine in subcohort B. The ORR and DCR were 36% and 47%, respectively. Presence of liver metastases was independently associated with lower ORR and DCR. The PFS and OS were 3.3 months and 7.7 months, respectively. Eastern Cooperative Oncology Group Performance Status (ECOG PS) and number of previous cycles of pembrolizumab were found to be independent prognostic factors associated with OS. CONCLUSION In a real-world setting, CHT showed clinically meaningful response rates and survival in mUC patients after progression with pembrolizumab. Clinical benefit may primarily be achieved in patients with favorable ECOG PS, in patients treated with > 6 cycles pembrolizumab as well as in patients without presence of liver metastases.
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Affiliation(s)
- Karin Holmsten
- Department of Oncology, S:t Görans Hospital, and Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden.
| | - Johanna Eknert
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Theme Cancer, Karolinska University Hospital, and Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden.
| | | | | | - Faith Jawdat
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Theme Cancer, Karolinska University Hospital, and Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | - Ingrida Verbiéné
- Department of Oncology, Akademiska University Hospital, Uppsala, Sweden
| | - Anna Laurell
- Department of Oncology, Akademiska University Hospital, Uppsala, Sweden
| | - Elin Jänes
- Department of Oncology, Sundsvall Härnösand County Hospital, Sundsvall, Sweden
| | - Johan Sandzén
- Department of Oncology, Karlstad County Hospital, Karlstad, Sweden
| | | | - Ida Lagstam
- Department of Oncology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Karin Söderkvist
- Department of Oncology, Norrland University Hospital, Umeå, Sweden
| | - Fernanda Costa Svedman
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Theme Cancer, Karolinska University Hospital, and Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
| | | | - Martin Bruzelius
- Department of Oncology, Västmanland County Hospital, Västerås, Sweden
| | | | - Sofia Kjellström
- Department of Oncology, Skåne University Hospital, Malmö, Sweden
| | | | - Helle Pappot
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
| | - Anders Ullén
- Department of Pelvic Cancer, Genitourinary Oncology and Urology Unit, Theme Cancer, Karolinska University Hospital, and Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden
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Choules MP, Zuo P, Otsuka Y, Garg A, Tang M, Bonate P. Physiologically based pharmacokinetic model to predict drug-drug interactions with the antibody-drug conjugate enfortumab vedotin. J Pharmacokinet Pharmacodyn 2023:10.1007/s10928-023-09877-5. [PMID: 37632598 DOI: 10.1007/s10928-023-09877-5] [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: 11/11/2022] [Accepted: 07/13/2023] [Indexed: 08/28/2023]
Abstract
Enfortumab vedotin is an antibody-drug conjugate (ADC) comprised of a Nectin-4-directed antibody and monomethyl auristatin E (MMAE), which is primarily eliminated through P-glycoprotein (P-gp)-mediated excretion and cytochrome P450 3A4 (CYP3A4)-mediated metabolism. A physiologically based pharmacokinetic (PBPK) model was developed to predict effects of combined P-gp with CYP3A4 inhibitor/inducer (ketoconazole/rifampin) on MMAE exposure when coadministered with enfortumab vedotin and study enfortumab vedotin with CYP3A4 (midazolam) and P-gp (digoxin) substrate exposure. A PBPK model was built for enfortumab vedotin and unconjugated MMAE using the PBPK simulator ADC module. A similar model was developed with brentuximab vedotin, an ADC with the same valine-citrulline-MMAE linker as enfortumab vedotin, for MMAE drug-drug interaction (DDI) verification using clinical data. The DDI simulation predicted a less-than-2-fold increase in MMAE exposure with enfortumab vedotin plus ketoconazole (MMAE geometric mean ratio [GMR] for maximum concentration [Cmax], 1.15; GMR for area under the time-concentration curve from time 0 to last quantifiable concentration [AUClast], 1.38). Decreased MMAE exposure above 50% but below 80% was observed with enfortumab vedotin plus rifampin (MMAE GMR Cmax, 0.72; GMR AUClast, 0.47). No effect of enfortumab vedotin on midazolam or digoxin systemic exposure was predicted. Results suggest that combination enfortumab vedotin, P-gp, and a CYP3A4 inhibitor may result in increased MMAE exposure and patients should be monitored for potential adverse effects. Combination P-gp and a CYP3A4 inducer may result in decreased MMAE exposure. No exposure change is expected for CYP3A4 or P-gp substrates when combined with enfortumab vedotin.ClinicalTrials.gov identifier Not applicable.
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Affiliation(s)
- Mary P Choules
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global, Inc., One Astellas Way, Northbrook, IL, 60062, USA.
| | - Peiying Zuo
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global, Inc., One Astellas Way, Northbrook, IL, 60062, USA
| | - Yukio Otsuka
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global, Inc., Tokyo, Japan
| | - Amit Garg
- Quantitative Pharmacology and Disposition, Seagen Inc., South San Francisco, CA, USA
| | - Mei Tang
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global, Inc., One Astellas Way, Northbrook, IL, 60062, USA
| | - Peter Bonate
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global, Inc., One Astellas Way, Northbrook, IL, 60062, USA
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Yamada T, Nakane K, Enomoto T, Tomioka M, Taniguchi T, Ishida T, Ozawa K, Takagi K, Ito H, Takeuchi S, Kawase M, Kawase K, Kato D, Takai M, Iinuma K, Yokoi S, Nakano M, Koie T. Oncological Outcomes in Patients with Metastatic Urothelial Carcinoma after Discontinuing Pembrolizumab as a Second-Line Treatment: A Retrospective Multicenter Real-World Cohort Study. Biomedicines 2022; 10:biomedicines10092243. [PMID: 36140344 PMCID: PMC9496337 DOI: 10.3390/biomedicines10092243] [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: 08/01/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
The treatment options are currently limited, and the oncological outcomes remain unclear, for patients with metastatic urothelial carcinoma (mUC) with or without third-line systemic therapy. We aimed to evaluate the oncological outcomes in real-world daily clinical practice after platinum-based chemotherapy followed by pembrolizumab for mUC. This retrospective, multicenter cohort study included patients with mUC who received second-line pembrolizumab in Japan. The patients were divided into the treatment group (those who received third-line treatment) and the BSC group (those who did not receive other treatments). The primary endpoint of this study was to evaluate the oncological outcomes. Of 126 patients enrolled in this study, 40 received third-line therapy. The median follow-up period was 8.0 months. The median overall survival (OS) times were nine months in the BSC group and 17 months in the treatment group (p < 0.001). The median progression-free survival (PFS) times were 4 months in the BSC group and 14 months in the treatment group (p < 0.001). In the multivariate analysis, performance status and liver metastasis were significantly associated with OS. Third-line therapy may have clinical potential advantages for improving the oncological outcomes in patients with mUC.
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Affiliation(s)
- Toyohiro Yamada
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan
| | - Keita Nakane
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan
| | - Torai Enomoto
- Department of Urology, Matsunami General Hospital, Hashima-gun 5016062, Japan
| | - Masayuki Tomioka
- Department of Urology, Japanese Red Cross Takayama Hospital, Takayama 5068550, Japan
- Department of Urology, Chuno Kosei Hospital, Seki 5013802, Japan
| | - Tomoki Taniguchi
- Department of Urology, Chuno Kosei Hospital, Seki 5013802, Japan
- Department of Urology, Ogaki Municipal Hospital, Ogaki 5038502, Japan
| | - Takashi Ishida
- Department of Urology, Gifu Municipal Hospital, Gifu 5008513, Japan
| | - Kaori Ozawa
- Department of Urology, Ogaki Municipal Hospital, Ogaki 5038502, Japan
| | - Kimiaki Takagi
- Department of Urology, Daiyukai Daiichi Hospital, Ichinomiya 4918551, Japan
| | - Hiroki Ito
- Department of Urology, Toyota Memorial Hospital, Toyota 4718513, Japan
| | - Shinichi Takeuchi
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan
| | - Makoto Kawase
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan
| | - Kota Kawase
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan
| | - Daiki Kato
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan
| | - Manabu Takai
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan
| | - Koji Iinuma
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan
| | - Shigeaki Yokoi
- Department of Urology, Central Japan International Medical Center, Minokamo 5058510, Japan
| | - Masahiro Nakano
- Department of Urology, Gifu Prefectural General Medical Center, Gifu 5008717, Japan
| | - Takuya Koie
- Department of Urology, Gifu University Graduate School of Medicine, Gifu 5011194, Japan
- Correspondence: ; Tel.: +81-582306000
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Hong J, Sung HH, Jeong BC, Park SH. Subsequent Systemic Therapy following Platinum and Immune Checkpoint Inhibitors in Metastatic Urothelial Carcinoma. Biomedicines 2022; 10:biomedicines10082005. [PMID: 36009553 PMCID: PMC9405748 DOI: 10.3390/biomedicines10082005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/03/2022] [Accepted: 08/16/2022] [Indexed: 11/29/2022] Open
Abstract
Treatment of metastatic urothelial carcinoma (mUC) after failure with platinum-based chemotherapy and immune checkpoint inhibitors (ICIs) remains controversial. To explore the role of subsequent systemic therapy, medical records from 436 patients who were consecutively treated with chemotherapy for mUC between May 2017 and April 2021 were collected from a single-center cancer registry. The primary endpoint was overall survival (OS), and progression-free survival (PFS) and response rate (RR) were also assessed. Among the 318 patients who failed both platinum and ICIs, subsequent therapy was delivered to 166 (52%) patients: taxanes (n = 56), platinum rechallenge (n = 46), pemetrexed (n = 39), and clinical trials (n = 25). Objective responses to third-line therapy were noted in 50 patients (RR, 30%; 95% CI, 23–37%). The patients who were enrolled in clinical trials and treated with platinum rechallenge were significantly more likely to respond than those treated with taxanes or pemetrexed. The median PFS and OS were 3.5 months (95% CI, 2.9–4.2 months) and 9.5 months (95% CI, 8.1–11.0 months), respectively. Similar to RR, PFS and OS were longer for the patients who were enrolled in clinical trials. Based on multivariate analyses, good performance status and enrollment in clinical trials are associated with benefits from subsequent therapy for pretreated mUC.
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Affiliation(s)
- Joohyun Hong
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Hyun Hwan Sung
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Se Hoon Park
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Correspondence:
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