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Lotan Y, Agarwal P, Black P, Dickstein R, Kamat AM, Lee B, Narayan VM, Porten S, Psutka SP, Smith AK, Svatek RS, Williams SB, Woldu S. Standardization of the evaluation and surveillance of patients with BCG unresponsive high grade non-muscle invasive bladder cancer clinical trials. Urol Oncol 2024; 42:223-228. [PMID: 38307803 DOI: 10.1016/j.urolonc.2024.01.019] [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: 11/12/2023] [Revised: 01/07/2024] [Accepted: 01/17/2024] [Indexed: 02/04/2024]
Abstract
There are multiple ongoing and planned clinical trials that are evaluating novel therapies to treat patients with BCG-unresponsive high grade nonmuscle invasive bladder cancer (NMIBC). Importantly, there is considerable variation in surveillance strategies between these clinical trials, specifically with regards to the use of advanced imaging, enhanced cystoscopy, and mandatory biopsies, which could impact landmark efficacy assessments of investigational agents. To present guideline recommendations for the standardization of cystoscopic evaluation, surveillance, and efficacy assessments for patients with BCG-unresponsive NMIBC participating in clinical trials. On September 29, 2023 at the annual meeting of the International Bladder Cancer Network, a breakout session was convened, during which representatives from various disciplines discussed potential guidance statements with opportunity for discussion and comment. A set of statements regarding use of white light and enhanced cystoscopy were developed to help guide a pragmatic approach to surveillance and efficacy assessments of patients in clinical trials. The use of "for cause" and "mandatory" biopsies was also addressed. A standard approach to evaluation of patients within the context of clinical trials is necessary to accurately assess the efficacy of novel agents, especially within single arm trials that lack an appropriate comparator. Additionally, the utilization and timing of mandatory biopsies is critical, as these biopsies may impact both disease evaluations and the determination of duration of response.
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Affiliation(s)
- Yair Lotan
- University of Texas Southwestern Medical Center, Dallas, TX.
| | | | - Peter Black
- Department of Urologic Sciences, University of British Columbia
| | - Rian Dickstein
- Department of Surgery-Urology, University of Maryland BWMC
| | - Ashish M Kamat
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Byron Lee
- Department of Urology, Glickman Urological and Kidney Institute
| | | | - Sima Porten
- Department of Urology, University of California, San Francisco
| | - Sarah P Psutka
- Department of Urology, University of Washington, Fred Hutchinson Cancer Center
| | | | - Robert S Svatek
- Department of Urology, University of Texas Health Science Center at San Antonio
| | - Stephen B Williams
- Division of Urology, Department of Surgery, University of Texas, Medical Branch Health System
| | - Solomon Woldu
- University of Texas Southwestern Medical Center, Dallas, TX
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Li R, Shah PH, Stewart TF, Nam JK, Bivalacqua TJ, Lamm DL, Uchio EM, Geynisman DM, Jacob JM, Meeks JJ, Dickstein R, Pearce SM, Kang SH, Jung SI, Kamat AM, Burke JM, Keegan KA, Steinberg GD. Oncolytic adenoviral therapy plus pembrolizumab in BCG-unresponsive non-muscle-invasive bladder cancer: the phase 2 CORE-001 trial. Nat Med 2024; 30:2216-2223. [PMID: 38844794 DOI: 10.1038/s41591-024-03025-3] [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: 04/05/2024] [Accepted: 04/29/2024] [Indexed: 06/20/2024]
Abstract
Cretostimogene grenadenorepvec is a serotype-5 oncolytic adenovirus designed to selectively replicate in cancer cells with retinoblastoma pathway alterations, previously tested as monotherapy in bacillus Calmette-Guérin (BCG)-experienced non-muscle-invasive bladder cancer. In this phase 2 study, we assessed the potential synergistic efficacy between intravesical cretostimogene and systemic pembrolizumab in patients with BCG-unresponsive non-muscle-invasive bladder cancer with carcinoma in situ (CIS). Thirty-five patients were treated with intravesical cretostimogene with systemic pembrolizumab. Induction cretostimogene was administered weekly for 6 weeks followed by three weekly maintenance infusions at months 3, 6, 9, 12 and 18 in patients maintaining complete response (CR). Patients with persistent CIS/high-grade Ta at the 3-month assessment were eligible for re-induction. Pembrolizumab was administered for up to 24 months. The primary endpoint was CR at 12 months as assessed by cystoscopy, urine cytology, cross-sectional imaging and mandatory bladder mapping biopsies. Secondary endpoints included CR at any time, duration of response, progression-free survival and safety. The CR rate in the intention-to-treat population at 12 months was 57.1% (20 out of 35, 95% confidence interval (CI) 40.7-73.5%), meeting the primary endpoint. A total of 29 out of 35 patients (82.9%, 95% CI 70.4-95.3%) derived a CR at 3 months. With a median follow-up of 26.5 months, the median duration of response has not been reached (95% CI 15.7 to not reached). The CR rate at 24 months was 51.4% (18 out of 35) (95% CI 34.9-68.0%). No patient progressed to muscle-invasive bladder cancer in this trial. Adverse events attributed to cretostimogene were low grade, self-limiting and predominantly limited to bladder-related symptoms. A total of 5 out of 35 patients (14.3%) developed grade 3 treatment-related adverse effects. There was no evidence of overlapping or synergistic toxicities. Combination intravesical cretostimogene and systemic pembrolizumab demonstrated enduring efficacy. With a toxicity profile similar to its monotherapy components, this combination may shift the benefit-to-risk ratio for patients with BCG-unresponsive CIS. ClinicalTrials.gov Identifier: NCT04387461 .
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Affiliation(s)
- Roger Li
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
- Department of Immunology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| | - Paras H Shah
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | | | - Jong Kil Nam
- Pusan National University, Yangsan Hospital, Yangsan, South Korea
| | | | | | | | - Daniel M Geynisman
- Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Joseph M Jacob
- Department of Urology, SUNY Medical Center, Upstate, Syracuse, NY, USA
| | - Joshua J Meeks
- Department of Urology, Northwestern University Medical Center, Chicago, IL, USA
| | | | | | - Seok Ho Kang
- Korea University, Anam Hospital, Seoul, South Korea
| | - Seung Il Jung
- Chonnam National University, Hwasun Hospital, Bundang, South Korea
| | - Ashish M Kamat
- Department of Urology, UT MD Anderson Cancer Center, Houston, TX, USA
| | | | - Kirk A Keegan
- CG Oncology, Irvine, CA, USA
- Department of Urology, Vanderbilt University, Nashville, TN, USA
| | - Gary D Steinberg
- Department of Urology, Rush University Medical Center, Chicago, IL, USA
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