IMPORTANCEAndrogen deprivation therapy (ADT) has been theorized to decrease the severity of SARS-CoV-2 infection in patients with prostate cancer owing to a potential decrease in the tissuebased expression of the SARS-CoV-2 coreceptor transmembrane protease, serine 2 (TMPRSS2). OBJECTIVE To examine whether ADT is associated with a decreased rate of 30-day mortality from SARS-CoV-2 infection among patients with prostate cancer. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed patient data recorded in the COVID-19 and Cancer Consortium registry between March 17, 2020, and February 11, 2021. The consortium maintains a centralized multi-institution registry of patients with a current or past diagnosis of cancer who developed COVID-19. Data were collected and managed using REDCap software hosted at Vanderbilt University Medical Center in Nashville, Tennessee. Initially, 1228patients aged 18 years or older with prostate cancer listed as their primary malignant neoplasm were included; 122 patients with a second malignant neoplasm, insufficient follow-up, or low-quality data were excluded. Propensity matching was performed using the nearest-neighbor method with a 1:3 ratio of treated units to control units, adjusted for age, body mass index, race and ethnicity, Eastern Cooperative Oncology Group performance status score, smoking status, comorbidities (cardiovascular, pulmonary, kidney disease, and diabetes), cancer status, baseline steroid use, COVID-19 treatment, and presence of metastatic disease. EXPOSURES Androgen deprivation therapy use was defined as prior bilateral orchiectomy or pharmacologic ADT administered within the prior 3 months of presentation with COVID-19. MAIN OUTCOMES AND MEASURESThe primary outcome was the rate of all-cause 30-day mortality after COVID-19 diagnosis for patients receiving ADT compared with patients not receiving ADT after propensity matching. RESULTSAfter exclusions, 1106 patients with prostate cancer (before propensity score matching: median age, 73 years [IQR, 65-79 years]; 561 (51%) self-identified as non-Hispanic White) were included for analysis. Of these patients, 477 were included for propensity score matching (169 who received ADT and 308 who did not receive ADT). After propensity matching, there was no significant difference in the primary end point of the rate of all-cause 30-day mortality (OR, 0.77; 95% CI, 0.42-1.42).

Background: Intravesical bacillus Calmette-Guérin (BCG) is the gold standard immunologic agent for treating patients with high-grade non-muscle invasive bladder cancer (NMIBC). Nevertheless, relapse rates remain high and BCG unresponsive NMIBC often requires bladder removal. Preclinical data suggest that priming with percutaneous BCG vaccine could improve response to intravesical BCG. Methods: A single-arm trial (NCT02326168) was performed to study the safety, immunogenicity, and preliminary efficacy of priming. Percutaneous BCG was given 21 days prior to intravesical BCG instillation in patients (n = 13) with high-risk NMIBC. Immune responses were monitored and compared to a sequentially enrolled cohort of nine control patients receiving only intravesical BCG. The effect of BCG on natural killer (NK) and γδ T cell in vitro cytotoxicity was tested. γδ T cell subsets were determined by T cell receptor gene expression with NanoString. Results: Priming was well tolerated and caused no grade ≥3 adverse events. The 3-month disease-free rate for prime patients was 85% (target goal ≥ 75%). Priming boosted BCG-specific immunity at 3 months and increased the activation status of in vitro expanded circulating NK and γδ T cells and their cytotoxicity against bladder cancer cells through receptor NKG2D. BCG enhanced the cytotoxicity of NK and γδ T cells against K562, RT4, and UM-UC6 but not against T24, UM-UC-3, or UM-UC-14 cells. Infiltrating γδ T cell subsets identified in the bladder includes γ9δ2 and γ8δ2. Conclusions: BCG priming is safe and tolerable. Poor sensitivity to NK and γδ T cell cytotoxicity by some bladder tumors represents a potential BCG-resistance mechanism.

Antitumor immune responses are largely mediated by cytotoxic lymphocytes (CD8+ T cells) that recognize tumor-associated antigens presented in the context of a major histocompatibility complex class I molecule (MHC I). However, many tumors downregulate MHC I expression as a means of immune escape. Under these conditions, additional effector lymphocytes, such as natural killer cells (NK cells) which mediate non-MHC restricted cytotoxicity, provide antitumor defenses. Although the presence of intratumoral CD8+ T cells has been associated with an improved survival in muscle-invasive bladder cancer, the role of other effector lymphocytes including NK cells in bladder cancer (BC) is less studied. Here, a comprehensive examination of intratumoral lymphocytes in murine and human urothelial tumors revealed a relatively high proportion of macrophages, γδ T cells and NK cells and whereas macrophages were detrimental, NK cells were protective to BC growth. γδ T cells and NK cells contribute to innate effector immune responses and likely crosstalk as γδ T cells can boost NK cell cytotoxic function. Our findings suggest that γδ T cells could potentially have a role in activating NK cells function marked by increased IFN-γ and TNF-α expression. In patients undergoing cystectomy for muscle-invasive BC, a higher frequency of intratumoral NK cells was associated with an improved survival and this association was maintained in MHC I low but not MHC I high tumors. Higher stage bladder tumors had a higher proportion of intratumoral CD56dim NK cells, which exhibit less cytotoxicity and IFN-γ secretion compared to their CD56bright counterparts. Moreover, bladder infiltrating CD56bright but not CD56dim NK cells predicted improved survival for cystectomy patients. Further, older patients with BC had significantly less intratumoral NK cells compared to younger patients. Interestingly, surface expression of CD56 on NK cells decreased with increasing patient age and the proportion of CD56bright subsets decreased with increasing age whereas the proportion of CD56dim subsets slightly increased with age. Finally, because intravesical Bacillus Calmette-Guérin (BCG) activates NK cells and is commonly used to treat non-muscle invasive BC, we conducted a proof-of-concept trial of administering BCG to patients with muscle-invasive BC prior to cystectomy. While intravesical BCG was well tolerated and increased the percentage of intratumoral NK cells in this neoadjuvant setting, it had no discernable antitumor activity and did not alter CD56 expression or functional status of intratumoral NK cells. We conclude that NK cells are protective in BC and the extent of an intratumoral CD56bright NK cells is a prognostic indicator in BC. While BCG may induce NK cells, alternative approaches to improve NK cell function in BC are warranted. Citation Format: Neelam Mukherjee, Niannian Ji, Maggie E. Tomasini, Vincent Hurez, Tyler J. Curiel, Maureen O. Montgomery, Andrew J. Braun, Marlo Nicolas, Marcela A. Flores, Qianqian Liu, Jianhua Ruan, Robert S. Svatek. Intratumoral CD56bright natural killer cells are associated with improved survival in bladder cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3792.

Bacillus Calmette-Guérin (BCG) is the gold standard immunologic agent for patients with high-grade non-muscle invasive bladder cancer (NMIBC). Nevertheless, responses to BCG are heterogeneous and limited options exist when BCG therapy fails. Preclinical data in animal models of bladder cancer (BC) suggests that priming with percutaneous BCG vaccine prior to intravesical BCG instillation can enhance BCG-specific immunity and improve outcome. To study the safety, immunogenicity and preliminary efficacy of this approach, we administered percutaneous BCG 21 days prior to intravesical BCG instillation in “prime patients” with NMIBC (n=13) in a prospective single-arm clinical trial. Immune responses and clinical outcomes were monitored and compared to a contemporaneous cohort of “control patients” (n=9) receiving intravesical BCG without prior percutaneous BCG. Priming was well tolerated and no grade ≥3 adverse events were observed. Compared to control, prime patients had improvement in both local and systemic measures of BCG-specific immunity, scored by increased post-BCG urinary IL-8 and IL-17A and increased circulating CD4, CD8, and γδ T cell proliferation and effector function in response to BCG. Furthermore, ex vivo cytotoxicity of circulating NK and γδ T cells against RT4 BC was significantly increased in prime patient after BCG treatment and was mediated in part by NKG2D, suggesting an important role of innate effector immune mechanisms underlying BCG’s antitumor activity. Remarkably, no prime patients progressed whereas 3 out of 9 control patients progressed to muscle-invasive disease and underwent cystectomy. Thus, BCG priming safely enhances BCG-specific immunity and could improve outcome for patients with NMIBC.

Antitumor immune responses are largely mediated by cytotoxic lymphocytes that recognize tumor-associated antigens presented in the context of a major histocompatibility complex class I molecule (MHC I). However, many tumors downregulate MHC I expression as a means of immune escape. Under these conditions, additional effector lymphocytes, such as natural killer cells (NK cells) which mediate non-MHC restricted cytotoxicity, provide antitumor defenses. Using flow cytometric analysis, we discovered that NK cells predominate among lymphocytes infiltrating human and carcinogen-induced mouse bladder cancer (BC). Using transcriptomics and clinical outcomes from the TCGA dataset we found that the presence of intratumoral NK cells is associated with increased survival after cystectomy, especially in low MHC class I expressing tumors. We validated this finding using a local BC cohort and determined that functional NK cells decline with increasing patient age. Using in vitro assays, we found that intratumoral NK cells from bladder tumors exhibit MHC class I dependent cytotoxicity against BC cells. Importantly, intratumoral CD56dim NK cells increase with higher pathologic stage and are less functional (cytotoxicity and cytokine secretion) than CD56bright counterparts. The presence of intratumoral CD56brightNK cells predicts improved patient survival independent of tumor stage. We conclude that intratumoral NK cells are functional and prognostically relevant in BC, but their presence and function is diminished with aging or tumor MHC class I. Intratumoral CD56bright NK cells are associated with better clinical outcomes whereas CD56dim NK cells are dysfunctional and associated with advanced BC.