Novel immunotherapeutic options for BCG‐unresponsive high‐risk non‐muscle‐invasive bladder cancer

Abstract

BackgroundHigh‐risk non‐muscle‐invasive bladder cancer (HR‐NMIBC) presents a challenge to many physicians due to its ability to resist Bacillus Calmette–Guérin (BCG) intravesical therapy and the substantial rate of progression into muscle‐invasive bladder cancer (MIBC). Patients who are BCG‐unresponsive have worse prognosis and thus require further management including radical cystectomy (RC), which significantly impacts quality of life. Moreover, the ongoing worldwide shortage of BCG warrants the need for policies that prioritize drug use and utilize alternative treatment strategies. Hence, there is a significant unmet need for bladder preserving therapy in this subset of patients.MethodsTo address this issue, we searched the relevant literature in PUBMED for articles published from 2019 through May of 2023 using appropriate keywords. All clinical trials of patients with HR‐NMIBC treated with immune‐related agents were retrieved from clinicaltrials.gov.Findings and Future PerspectivesExploratory treatments for BCG‐Unresponsive HR‐NMIBC included immune checkpoint inhibitors (ICI), oncolytic viral therapy, cytokine agonists, and other immunomodulators targeting TLR, EpCaM, FGFR, MetAP2, and IDO1. Some combination therapies have been found to work synergistically and are preferred therapeutically over monotherapy. Three drugs—pembrolizumab, valrubicin, and most recently, nadofaragene firadenovec‐vncg—have been FDA approved for the treatment of BCG‐unresponsive NMIBC in patients who are ineligible for or decline RC. However, all explored treatment options tend to postpone RC rather than provide long‐term disease control. Additional combination strategies need to be studied to enhance the effects of immunotherapy. Despite the challenges faced in finding effective therapies, many potential treatments are currently under investigation. Addressing the landscape of biomarkers, mechanisms of progression, BCG resistance, and trial design challenges in HR‐NMIBC is essential for the discovery of new targets and the development of effective treatments.

Efficacy of Intravesical Nadofaragene Firadenovec for Patients With Bacillus Calmette-Guérin–Unresponsive Nonmuscle-Invasive Bladder Cancer: 5-Year Follow-Up From a Phase 3 Trial

“…Valrubicin demonstrated a CR of 21% in patients with BCG-refractory CIS; however, this trial was conducted before a standardized definition for BCG-unresponsive disease. 11,12 Pembrolizumab was studied in KEYNOTE-057, with 39 participants (41%) with BCG-unresponsive CIS achieving a CR at 3 months, but nearly 22% of patients experienced immune-related AEs. 13 Other intravesical therapies that have been investigated include gemcitabine and docetaxel monotherapy, 14,15 combinations including gemcitabine/mitomycin and gemcitabine/ docetaxel, 16 and nab-paclitaxel.…”

Strategies for Overcoming Immune Evasion in Bladder Cancer

“…For patients diagnosed with MIBC, common treatment options include cisplatin chemotherapy or radical cystectomy. Nevertheless, there are instances in which patients are unsuitable for chemotherapy or choose not to undergo cystectomy [ 133 ]. In such cases, ICIs can serve as an alternative treatment method for MIBC patients [ 133 ].…”

“…Nevertheless, there are instances in which patients are unsuitable for chemotherapy or choose not to undergo cystectomy [ 133 ]. In such cases, ICIs can serve as an alternative treatment method for MIBC patients [ 133 ]. Especially in the context of MIBC, ICI stands out as a significant treatment option due to its lower rates of recurrence and survival rates, even after cystectomy [ 134 ].…”

“…Especially in the context of MIBC, ICI stands out as a significant treatment option due to its lower rates of recurrence and survival rates, even after cystectomy [ 134 ]. As of 2023, the FDA has approved three drugs (pembrolizumab, valrubicin, and nadofaragene firadenovec-vcng) for patients unresponsive to BCG and either ineligible for chemotherapy or refusing radical cystectomy [ 133 ].…”