News stories coming out of the 7th European Multidisciplinary Meeting on Urological Cancers (EMUC) were focused on the emerging role of immunotherapy and radiotherapy in bladder, renal, and prostate cancer. That news is generally positive, especially in bladder cancer, which hasn’t had significant advances in the treatment arena in more than 30 years.
Checkpoint inhibitors and agents that target the PD-1 and PD-L1 pathway have led to, in some cases, dramatic improvements in lung and melanoma. Now those agents have also shown great promise in bladder cancer, according to Thomas Powles, MD, medical oncologist, director of St Bartholomew’s Cancer Centre, London, who updated attendees during a talk titled “Update on Systemic Treatments in Bladder Cancer.” He highlighted studies involving atezolizumab, pembrolizumab, nivolumab, and ipilimumab.
He cited a phase I trial of second line atezolizumab (MPDL3280A) in transitional cell carcinoma (TCC) wherein response was demonstrated in patients that had previously showed only a 10% response rate to chemotherapy. The ORRs were 43% for patients with tumors expressing high levels of PD-L1 (IHC 2/3) compared to 11% in patients with tumors having low expression (IHC 0 or 1).
Combination and adjuvant studies are ongoing according to Powles. A trial of atezolizumab as adjuvant therapy versus placebo is underway in patients with TCC whose tumors express PD-L1. The trial has a primary endpoint of diseasefree survival (DFS).
The role of immunotherapy in renal cell carcinoma (RCC) is equally positive according to David F. McDermott, MD, Beth Israel Deaconess Medical Center in his presentation titled, “Understanding the Immunology of Advanced RCC: The Role of Checkpoint Inhibitors.”
The next frontiers for immunotherapy in RCC are biomarkers and combination strategies. Additionally, studies have sought to combine PD-1 inhibitors with CTLA-4- targeted agents, TKIs, and chemotherapy.
The feature story this month addresses managing the patient with high-risk, localized prostate cancer. In this population, the urologist can manage the patient with surgery or radiation therapy with accompanying hormonal treatment.
Historically, radical prostatectomy (RP) had been avoided in these patients—mostly because of the impotence and incontinence associated with the procedure. But that trend may be shifting as more observational studies suggest that RP is not only appropriate for this population, but also may be a more optimal initial treatment, given that many of these patients require multimodal therapy to manage their disease.
Stacy Loeb, MD, an assistant professor of Urology and Population Health at New York University Langone Medical Center, told Urologists in Cancer Care that a patient who undergoes a RP can undergo radiation and hormonal therapy at a later date. That is because if radiation is administered first, the remaining prostate tissue can be damaged. Subsequent surgery is difficult to perform on the treated tissue, and is only performed at select hospitals around the world.
The question about radiation versus surgery lies in the details, and can only be made after the patient’s overall health, life expectancy, and disease risk are considered, according to Matthew Cooperberg, MD, associate professor in the departments of Urology and Epidemiology & Biostatistics, Helen Diller Family Chair in Urology, University of California San Francisco.