Minimal Residual Disease Detection with Urine-derived DNA Is Prognostic for Recurrence-free Survival in Bacillus Calmette-Guérin-unresponsive Non-muscle-invasive Bladder Cancer Treated with Nadofaragene Firadenovec

Urine Tumor DNA to Stratify the Risk of Recurrence in Patients Treated with Atezolizumab for Bacillus Calmette-Guérin-unresponsive Non-muscle-invasive Bladder Cancer

As new treatments for bacillus Calmette-Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer (NMIBC) emerge, better methods are needed to guide therapeutic decisions. This study analyzed urine tumor DNA (utDNA) from patients treated with atezolizumab in the SWOG S1605 trial to determine whether utDNA profiling can stratify the risk of treatment failure. Urine samples were analyzed using the UroAmp assay at baseline and 3 mo from 89 and 77 patients, respectively. Only 13% of UroAmp-positive patients at baseline achieved a complete response at 6 mo compared with 71% of UroAmp-negative patients (p < 0.001). The 18-mo event-free survival (EFS) was significantly lower for UroAmp-positive patients at baseline (23%) than for UroAmp-negative patients (51%; hazard ratio [HR] 2.8, p < 0.001). Among patients with no clinical evidence of disease at 3 mo (n = 51), the 18-mo EFS was 38% for UroAmp-positive and 86% for UroAmp-negative (HR 3.5, p = 0.01) patients. These findings suggest that utDNA profiling at baseline and after 3 mo of treatment can help identify patients with BCG-unresponsive NMIBC who are less likely to benefit from systemic immunotherapy.

Management Dilemma for Very High-risk Non-muscle-invasive Bladder Cancer: Real-World Data Challenge the Guideline Recommendation for Upfront Radical Cystectomy

We discuss real-world evidence that challenges the guideline recommendation of upfront radical cystectomy for all patients with very high-risk non-muscle-invasive bladder cancer. The evidence highlights the need for more accurate and dynamic tools to guide clinical decision-making. Until these are available, treatment decisions should be individualized and made in close consultation with the patient.

Integrating gene therapy into the treatment paradigm for non-muscle invasive bladder cancer

INTRODUCTION

Approximately 75% of bladder cancer cases are non-muscle invasive at diagnosis. Drug development for non-muscle invasive bladder cancer (NMIBC) has historically lagged behind that of other malignancies. No treatment has demonstrated the ability to overcome drug resistance that ultimately leads to recurrence and progression. Gene therapy is emerging as a promising option for patients with NMIBC.

AREAS COVERED

This review summarizes the clinical application of gene therapy in NMIBC management and discusses recent clinical trials involving the adenoviral vector-based treatment nadofaragene firadenovec, and the oncolytic serotype 5 adenovirus, cretostimogene grenadenorepvec. Nadofaragene received approval by the Food and Drug Administration in December 2022, and cretostimogene has been granted Fast Track Designation and Breakthrough Therapy Designation. Ongoing trials are investigating strategies to augment efficacy and durability of these therapies.

EXPERT OPINION

Gene therapy may overcome resistance mechanisms of other NMIBC treatments, and data suggest a role for combination therapy with additive or synergistic agents. Significant differences in trial design limit comparability of agents across trials, highlighting the need for critical assessment of published findings. While initial investigations were in high-risk patients who recur despite frontline therapy with Bacillus Calmette-Guerin (BCG), there is growing interest in BCG-naïve and intermediate-risk populations.