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Necchi A, Van der Heijden MS, Trukhin D, Peer A, Gurney H, Alekseev BY, Parnis FX, Leibowitz R, De Santis M, Grivas P, Clark J, Munteanu M, Kataria R, Jia C, Balar AV, de Wit R. Pembrolizumab plus either epacadostat or placebo for cisplatin-ineligible urothelial carcinoma: results from the ECHO-307/KEYNOTE-672 study. BMC Cancer 2024; 23:1252. [PMID: 39054491 PMCID: PMC11270764 DOI: 10.1186/s12885-023-10727-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 03/08/2023] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Indoleamine 2,3- dioxygenase 1 (IDO1) is an immunosuppressive enzyme that has been correlated with shorter disease-specific survival in patients with urothelial carcinoma (UC). IDO1 may counteract the antitumor effects of immune checkpoint inhibitors. Epacadostat is a potent and highly selective inhibitor of IDO1. In the phase I/II ECHO-202/KEYNOTE-037 study, epacadostat plus pembrolizumab resulted in a preliminary objective response rate (ORR) of 35% in a cohort of patients with advanced UC. METHODS ECHO-307/KEYNOTE-672 was a double-blinded, randomized, phase III study. Eligible adults had confirmed locally advanced/unresectable or metastatic UC of the urinary tract and were ineligible to receive cisplatin-based chemotherapy. Participants were randomly assigned (1:1) to receive epacadostat (100 mg twice daily) plus pembrolizumab (200 mg every 3 weeks) or placebo plus pembrolizumab for up to 35 pembrolizumab infusions. The primary endpoint was investigator-assessed ORR per Response Evaluation Criteria in Solid Tumors (version 1.1). RESULTS A total of 93 patients were randomized (epacadostat plus pembrolizumab, n = 44; placebo plus pembrolizumab, n = 49). Enrollment was stopped early due to emerging data from the phase III ECHO-301/KEYNOTE-252 study. The median duration of follow-up was 64 days in both arms. Based on all available data at cutoff, ORR (unconfirmed) was 31.8% (95% CI, 22.46-55.24%) for epacadostat plus pembrolizumab and 24.5% (95% CI, 15.33-43.67%) for placebo plus pembrolizumab. Circulating kynurenine levels numerically increased from C1D1 to C2D1 in the placebo-plus-pembrolizumab arm and decreased in the epacadostat-plus-pembrolizumab arm. Epacadostat-plus-pembrolizumab combination treatment was well tolerated with a safety profile similar to the placebo arm. Treatment discontinuations due to treatment-related adverse events were more frequent with epacadostat (11.6% vs. 4.1%). CONCLUSIONS Treatment with epacadostat plus pembrolizumab resulted in a similar ORR and safety profile as placebo plus pembrolizumab in cisplatin-ineligible patients with previously untreated locally advanced/unresectable or metastatic UC. At a dose of 100 mg twice daily, epacadostat did not appear to completely normalize circulating kynurenine levels when administered with pembrolizumab. Larger studies with longer follow-up and possibly testing higher doses of epacadostat, potentially in different therapy settings, may be warranted. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03361865, retrospectively registered December 5, 2017.
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MESH Headings
- Humans
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Male
- Female
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Aged
- Sulfonamides/therapeutic use
- Sulfonamides/administration & dosage
- Sulfonamides/adverse effects
- Cisplatin/therapeutic use
- Cisplatin/administration & dosage
- Cisplatin/adverse effects
- Double-Blind Method
- Middle Aged
- Urologic Neoplasms/drug therapy
- Urologic Neoplasms/pathology
- Aged, 80 and over
- Carcinoma, Transitional Cell/drug therapy
- Carcinoma, Transitional Cell/pathology
- Adult
- Indoleamine-Pyrrole 2,3,-Dioxygenase/antagonists & inhibitors
- Indoleamine-Pyrrole 2,3,-Dioxygenase/metabolism
- Oximes
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Affiliation(s)
- Andrea Necchi
- Vita-Salute San Raffaele University Milan, Milan, Italy.
- Department of Medical Oncology, IRCCS San Raffaele Hospital and Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
| | | | | | | | | | | | - Francis X Parnis
- Adelaide Cancer Centre, Kurralta Park, Australia
- University of Adelaide, Adelaide, Australia
| | - Raya Leibowitz
- Oncology Institute, Shamir Medical Center, Be'er yaakov, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maria De Santis
- Department of Urology, Charité Universitätsmedizin, Berlin, Germany
- Medical University Vienna, Wien, Austria
| | - Petros Grivas
- University of Washington, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Jason Clark
- Incyte Corporation, Wilmington, Delaware, USA
| | | | | | | | - Arjun V Balar
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Medical Center, New York, NY, USA
| | - Ronald de Wit
- Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands
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Chu C, Pietzak E. Immune mechanisms and molecular therapeutic strategies to enhance immunotherapy in non-muscle invasive bladder cancer: Invited review for special issue "Seminar: Treatment Advances and Molecular Biology Insights in Urothelial Carcinoma". Urol Oncol 2023; 41:398-409. [PMID: 35811207 PMCID: PMC10167944 DOI: 10.1016/j.urolonc.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 03/12/2022] [Accepted: 05/07/2022] [Indexed: 11/26/2022]
Abstract
Intravesical immunotherapy with Bacillus Calmette-Guérin (BCG) has been the standard of care for patients with high-risk non non-muscle invasive bladder cancer (NMIBC) for over four decades. Despite its success as a cancer immunotherapy, disease recurrence and progression remain common. Current efforts are focused on developing effective and well-tolerated alternatives to BCG and salvage bladder preservation therapies after BCG has failed. The focus of this review is to synthesize our current understanding of the molecular biology and tumor immune microenvironment of NMIBC to provide rationale for existing and emerging therapeutic targets. We highlight recent and ongoing clinical trials and define the current treatment landscape, challenges, and future directions of salvage treatment. Combination regimens that are rationally designed will be needed to make meaningful therapeutic advancements. Investigations into the molecular underpinnings of NMIBC are leading to the emergence of predictive molecular biomarkers that provide greater insight into the clinical heterogeneity of NMIBC and enable us to identify drivers of treatment resistance and new therapeutic targets.
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Affiliation(s)
- Carissa Chu
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eugene Pietzak
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Weill Cornell Medical College, New York, NY.
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Al Hussein Al Awamlh B, Chang SS. Novel Therapies for High-Risk Non-Muscle Invasive Bladder Cancer. Curr Oncol Rep 2023; 25:83-91. [PMID: 36571706 PMCID: PMC9791638 DOI: 10.1007/s11912-022-01350-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW The treatment options for high-risk non-muscle invasive bladder cancer (NMIBC), particularly following BCG, remain limited. We highlight recent, promising therapies for high-risk NMIBC. RECENT FINDINGS Several therapies utilizing different mechanisms of action have demonstrated favorable results in the BCG-naïve and BCG-unresponsive settings. These treatments include intravenous and intravesical immunotherapy, viral- and bacterial-based intravesical therapies, combination intravesical chemotherapy regimens, and novel intravesical chemotherapy administration. Overall, the efficacy and tolerability of emerging treatments for NMIBC appear promising and provide potential alternatives to radical cystectomy. As the landscape of managing BCG-unresponsive disease evolves, clinical trials will explore future options and determine effective alternatives.
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Affiliation(s)
- Bashir Al Hussein Al Awamlh
- Department of Urology, Vanderbilt University Medical Center, A-1302 Medical Center Drive, Nashville, TN 37232 USA
| | - Sam S. Chang
- Department of Urology, Vanderbilt University Medical Center, A-1302 Medical Center Drive, Nashville, TN 37232 USA
- Vanderbilt Ingram Cancer Center, Nashville, TN USA
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Lobo N, Martini A, Kamat AM. Evolution of immunotherapy in the treatment of non-muscle-invasive bladder cancer. Expert Rev Anticancer Ther 2022; 22:361-370. [PMID: 35212590 DOI: 10.1080/14737140.2022.2046466] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Immunotherapy with intravesical bacillus Calmette-Guérin (BCG) has been the gold standard treatment for intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC) for nearly half a century. Yet, many patients with high-risk disease will experience recurrence, including those who progress and eventually become unresponsive to BCG. For decades, apart from radical cystectomy, few therapeutic options existed for this at-risk population. However, the advent of novel immunotherapeutic agents has transformed treatment in a range of tumour types, including urothelial carcinoma. These immunotherapies have yielded promising results in the treatment of metastatic urothelial carcinoma and, as such, are also being investigated for use in NIMIBC. AREAS COVERED This article provides an overview of the evolution of immunotherapy for NMIBC, beginning from the original immunotherapy- BCG - to current agents including checkpoint inhibitors, IL-15 agonists, viral gene therapies and therapeutic cancer vaccines. EXPERT OPINION The KEYNOTE-057 trial represented a pivotal moment for immunotherapy in NMIBC, but patient selection and the development of biomarkers to guide the identification of patients who will benefit most from a particular immunotherapy remains critical. As research efforts come to fruition, novel immunotherapies may become integrated into the standard treatment paradigm for intermediate- and high-risk NMBIC.
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Affiliation(s)
- Niyati Lobo
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alberto Martini
- Department of Urology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ashish M Kamat
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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