Long Term Disease Free Survival Benefits with Adjuvant OPDIVO® in Urothelial Carcinoma

SUMMARY: The American Cancer Society estimates that in the United States for 2022, about 81,180 new cases of bladder cancer will be diagnosed and approximately 17,100 patients will die of the disease. Bladder cancer is the fourth most common cancer in men, but it is less common in women. A third of the patients initially present with locally invasive disease. Even though radical cystectomy is considered the standard of care for patients with localized Muscle Invasive Bladder Cancer (MIBC), two large randomized trials and two meta-analyses have shown greater survival benefit with neoadjuvant Cisplatin-based combination chemotherapy for patients with MIBC, compared to surgery alone. However, not all patients with MIBC benefit from neoadjuvant Cisplatin based therapy, with only 25-50% attaining a pathologic response. More than 50% of patients with MIBC or regional lymph node involvement will develop metastatic disease following radical cystectomy. There is presently no clear consensus with regards to the routine use of adjuvant Cisplatin-based chemotherapy. Further, not all patients are eligible for adjuvant or neoadjuvant Cisplatin-based chemotherapy.

OPDIVO®(Nivolumab) is a fully human, immunoglobulin G4 monoclonal antibody that binds to the PD-1 receptor and blocks its interaction with PD-L1 and PD-L2. Blocking the Immune checkpoint proteins unleashes the T cells, resulting in T cell proliferation, activation and a therapeutic response. OPDIVO® has been shown to have antitumor activity in patients with metastatic urothelial carcinoma who had previously received platinum treatment, and is presently approved by the FDA for this patient group, as well as adjuvant treatment of patients with urothelial carcinoma who are at high risk of recurrence after undergoing radical resection.

CheckMate 274 is a multicenter, double-blind, randomized, Phase III trial conducted to evaluate the efficacy and safety of adjuvant OPDIVO®, as compared with placebo, in patients with muscle-invasive urothelial carcinoma following radical surgery (with or without previous neoadjuvant Cisplatin-based combination chemotherapy). A total of 709 patients with muscle-invasive urothelial carcinoma who had undergone radical surgery were randomly assigned in a 1:1 ratio to receive either OPDIVO® 240 mg as a 30-minute IV infusion (N=353) or placebo (N=356), every 2 weeks for up to 1 year. To be eligible, patients must have had radical surgery (R0, with negative surgical margins), with or without neoadjuvant Cisplatin-based chemotherapy. Patients must have had pathological evidence of urothelial carcinoma (originating in the bladder, ureter or renal pelvis) with a high risk of recurrence defined as follows: pathological stage of pT3, pT4a, or pN+ and patients not eligible for or declined adjuvant Cisplatin-based combination chemotherapy, patients who had not received neoadjuvant Cisplatin-based chemotherapy, and pathological stage of ypT2 to ypT4a or ypN+ for patients who received neoadjuvant Cisplatin. The mean age was 65.3 years and both treatment groups were well balanced. Approximately 40% of patients in both treatment groups had PD-L1 expression of 1% or more and 43% of patients had received previous neoadjuvant Cisplatin therapy. The two Primary endpoints were Disease Free Survival (DFS) among all the patients, and among patients with a tumor Programmed Death-Ligand 1 (PD-L1) expression level of 1% or more. Secondary endpoints included NonUrothelial Tract Recurrence-Free Survival (NUTRFS) and Distant Metastasis-Free Survival (DMFS), Overall Survival and Safety.

The authors in this publication reported the DFS outcomes, with 5 additional months of follow up, in all randomized patients. Patients with high-risk, muscle-invasive urothelial carcinoma continued to experience clinically meaningful improvements in Disease Free Survival (DFS), with a median DFS of 22.0 months among those receiving OPDIVO® (95% CI, 17.7-36.9) compared with 10.9 months (95% CI, 8.3-14.0) among those receiving placebo (HR=0.70; 95% CI, 0.57-0.85). The DFS probability at 12 months was 63.5% with OPDIVO® versus 46.9% with placebo. The DFS benefit was even more significant in patients with PD-L1 expression of 1% or more and was Not Reached in the OPDIVO® group versus 8.4 months in the placebo group (HR, 0.53; 95% CI, 0.38-0.75). The DFS probability at 12 months was 67.6% with OPDIVO® versus 46.3% with placebo. The DFS benefits was observed with OPDIVO® among most subgroups analyzed, including age, sex, ECOG PS, nodal status and use of prior Cisplatin-based chemotherapy.

NonUrothelial Tract Recurrence-Free Survival (NUTRFS) and Distant Metastasis-Free Survival (DMFS) were also improved with OPDIVO® when compared to placebo, both in all randomized patients, as well as patients with PD-L1 expression of 1% or more.

It was concluded that with longer follow up, OPDIVO® continued to show clinically meaningful improvement in Disease Free Survival among patients with high-risk muscle-invasive urothelial carcinoma, when compared to placebo, both in all randomized patients, as well as patients with PD-L1 expression of 1% or more. OPDIVO® also improved NonUrothelial Tract Recurrence-Free Survival (NUTRFS) and Distant Metastasis-Free Survival when compared to Placebo. The authors added that these results support adjuvant OPDIVO® as a Standard of Care for high risk muscle-invasive urothelial carcinoma patients after radical surgery.

Galsky M, Witjes JA, Gschwend JE, et al. Disease-free survival with longer follow-up from the CheckMate 274 trial of adjuvant nivolumab in patients after surgery for high-risk muscle-invasive urothelial carcinoma. J Urol. 2022;207(suppl 5):e183. doi:10.1097/JU.0000000000002536.01

Early-Stage Multi-Cancer Detection Using an Extracellular Vesicle Protein-Based Blood Test

SUMMARY: The American Cancer Society’s estimates that in 2022, about 62,210 people will be diagnosed with pancreatic cancer and 49,830 people will die of the disease, 19,880 women will receive a new diagnosis of ovarian cancer and about 12,810 women will die of the disease, and about 81,800 new cases of bladder cancer will be diagnosed in 2022 and about 17,100 patients will die of the disease. These three cancer types are estimated to account for approximately 80,000 deaths in the US in 2022. Detecting cancer at early stages can significantly increase survival rates and outcomes.

Several multi-cancer early detection tests are being developed that involve blood-based circulating cell-free tumor DNA (cfDNA) in the plasma, to track hundreds of patient-specific mutations, to detect Minimal Residual Disease (MRD) , as well as detection of abnormal methylation patterns, followed by machine learning approaches, to differentiate between cancer and non-cancer, for detecting clinically significant, late-stage (III and IV) cancers. Early detection of cancer however is the key to improving survival. This is particularly relevant for certain cancer types. Pancreatic Ductal AdenoCarcinoma (PDAC) is one of the deadliest cancers, and a leading cause of all cancer-related deaths in the United States, and is typically detected when the disease is advanced. However, when detected at Stage I, survival rates can be as high as 80%. Ovarian cancer is often detected when the disease is advanced and the 5-year survival rates are less than 30%, but can be as high as 93% when detected early. The same holds true for metastatic bladder cancer, with 5-year survival rates of only 6%, whereas while detected when the tumor is still localized to the bladder wall inner layer results in a 5-year survival rate of 96%. Even though serum CA19-9 is intended as an aid in the management of patients with confirmed pancreatic cancer for serial monitoring of their response to therapy and disease progression, it is not recommended by the FDA for screening, as it may be elevated in several benign conditions. Similarly, serum CA-125 is FDA approved for use in monitoring patients with ovarian cancer for disease persistence and recurrence, but is not recommended to screen for ovarian cancer. Currently, there are few general screening strategies to detect asymptomatic, early-stage PDAC, ovarian, or bladder cancer and there is therefore a significant unmet need in this patient group.

Exosomes are 30-150 nm-sized Extracellular Vesicles (EVs) secreted by multiple different cell types and ejected by tumors into the bloodstream. They mediate intercellular signaling by transferring mRNAs and microRNAs between distant cells and tissues and therefore carry functional protein biomarkers representing the tumor proteome. Exosomes represent one potential approach for more sensitive detection of cancer-related biomarkers from blood.

The researchers in this study used an Alternating Current Electrokinetic (ACE)-based platform (Verita™ System) to efficiently isolate EVs from soluble contaminants such as cells, small proteins, or other vesicles from patient samples, and then measured the concentrations of associated protein biomarkers (“EV proteins”) present in the purified EV samples from our case-control study subjects. The researchers chose this platform over the current gold standard ultracentrifugation method, which the authors felt was inefficient and not suitable for point-of-care applications. Artificial Intelligence machine-learning algorithm developed by the researchers, enabled detection of early-stage pancreatic, ovarian, and bladder cancers.

In this case-control pilot study, 139 pathologically confirmed Stage I and II cancer cases representing pancreatic, ovarian, or bladder patients were compared with 184 control subjects, using the Verita™ System. The Extracellular Vesicles (EVs) isolated using this technology, were consistent with the presence of Exosomes, in accordance with the International Society for Extracellular Vesicles (ISEV) 2018 guidelines. The researchers selected a panel of 13 Extracellular Vesicle (EV) proteins along with age, a known cofactor in cancer. In order to simulate a real-world screening scenario, all cancer cases were treatment-naïve and to ensure that these were early-stage patients, the histopathologic staging was confirmed using the American Joint Commission on Cancer (AJCC) guidelines. The median age of the cancer cases was 60 years and 63.3% of the overall cancer cases were Stage I, with the remaining 36.7% at Stage II. The median age of the control group was 57 years and had no known history of cancer, autoimmune diseases, neurodegenerative disorders or diabetes mellitus.

When the overall cancer case cohort was compared with the control individuals using the EV protein biomarker test, the average sensitivity was 71.2%, at a specificity of 99.5%. When considered across all the three cancers studied, EV protein biomarker test using this technology demonstrated similar sensitivities of 70.5% and 72.5% for Stage I and II patients, respectively. This new technology detected 95.5% of Stage I pancreatic cancers, 73.1% of pathologic Stage IA lethally aggressive serous ovarian adenocarcinomas and 43.8% in bladder cancer, demonstrating the potential value of this platform for detection of early stage cancers. The lower sensitivity for detecting early stage bladder cancer may be due to high molecular and histologic heterogeneity of bladder tumors.

It was concluded from this study that blood-based EV protein detection test has potential clinical value for early cancer detection and the use of Verita™ platform resulted in the accurate detection of early stage pancreatic, ovarian, or bladder cancer. The authors added that mortality from pancreatic cancer which will soon become the second leading cause of cancer mortality in the U.S., can be greatly reduced if this study results are validated.

Early-stage multi-cancer detection using an extracellular vesicle protein-based blood test. Hinestrosa, J.P., Kurzrock, R., Lewis, J.M. et al. Commun Med 2, 29 (2022). https://doi.org/10.1038/s43856-022-00088-6.

Platelet-to-Lymphocyte Ratio Predicts the Efficacy of KEYTRUDA® in Patients with Urothelial Carcinoma

SUMMARY: Immunotherapy with PD-1/PD-L1 (Programmed Death-1/Programmed Death-Ligand 1) inhibitors, also called Immune Checkpoint Inhibitors (ICIs), has dramatically changed the treatment paradigm for patients with solid tumors, with significant improvement in outcomes. However, even among those with tumors expressing high PD-L1 expression and high Tumor Mutation Burden, not all patients benefit from Immunotherapy with ICIs. Therefore identifying biomarkers for patients likely to respond to ICI therapy, and predicting resistance is important and relevant, in selecting the appropriate patients for treatment with ICIs.

There is growing body of evidence on the role of inflammation in cancer biology, and systemic inflammatory response may have prognostic significance in different cancer types. Inflammatory process in various cancers imparts immunoresistance to ICIs, by activating oncogenic signaling pathways, there by promoting cancer growth and dissemination, with resulting poor outcomes.

More recently, attention has been focused on the predictive role of Platelet-Lymphocyte ratio (PLR) as an effective indicator of the severity of systemic inflammatory response. PLR is defined as the ratio of platelets to lymphocytes. Platelets and lymphocytes play multiple roles in the inflammatory response. Increased platelet count accelerates tumor progression by promoting neoangiogenesis and the production of adhesion molecules, whereas lymphocytes activate anti-tumor immunity by releasing a range of cytokines. Elevated PLR has been associated with poor prognosis in multiple solid tumors. In a meta-analysis of data from 12 related studies involving a total of 1340 patients, high PLR in cancer patients was associated with poor efficacy when treated with Immune Checkpoint Inhibitors, and poor prognosis. (https://doi.org/10.1016/j.intimp.2019.105957Get rights and content). Several other studies suggest that using PLR to predict the prognosis of cancer patients treated with immunotherapy remains controversial. The role of PLR in the prognosis of cancer patients treated with immunotherapy has thus remained unclear.

The present study was conducted to determine meaningful predictive factors for selecting patients with advanced Urothelial Carcinoma (UC) who might benefit clinically from treatment with Immune Checkpoint Inhibitor, KEYTRUDA® (Pembrolizumab). KEYTRUDA® is a fully humanized, Immunoglobulin G4, anti-PD-1, monoclonal antibody, that binds to the PD-1 receptor and blocks its interaction with ligands PD-L1 and PD-L2. It thereby reverses the PD-1 pathway-mediated inhibition of the immune response, and unleashes the tumor-specific effector T cells. The researchers retrospectively analyzed 54 patients who received treatment with KEYTRUDA® for Urothelial Carcinoma. Patient’s Hemoglobin, Albumin, Lymphocyte and Platelet (HALP) score, Neutrophil-to-Lymphocyte Ratio (NLR), and Platelet-to-Lymphocyte Ratio (PLR) were calculated as indices of systemic inflammatory response. The relationships between these scores and the initial tumor response or Overall Survival, as well as other clinicopathological factors, were then assessed.

It was noted that a high NLR and PLR were associated with a poor initial tumor response to KEYTRUDA®. A HALP score less than 30.05 and a PLR of 173.73 or more were associated with worse Overall Survival. In the multivariate analysis, a high PLR was a significant independent prognostic factor for unfavorable outcomes.

The authors concluded from this study that a high pretreatment Platelet-to-Lymphocyte Ratio may be a valuable indicator for choosing therapy other than KEYTRUDA® in patients with advanced Urothelial Carcinoma, and may be a potential biomarker for immunotherapy.

Platelet-to-Lymphocyte Ratio Predicts the Efficacy of Pembrolizumab in Patients With Urothelial Carcinoma. Kurashina R, Ando K, Inoue M, et al. Anticancer Research February 2022;42:1131-1136.

KEYTRUDA® for BCG-Unresponsive High-Risk Non-Muscle Invasive Bladder Cancer

SUMMARY: The American Cancer Society estimates that for 2021, about 83,730 new cases of bladder cancer will be diagnosed in the US and about 17,200 patients will die of the disease. Bladder cancer is the fourth most common cancer in men, but is less common in women and the average age at the time of diagnosis is 73. With regards to racial predisposition, Caucasians are more likely to be diagnosed with bladder cancer than African Americans or Hispanic Americans.

Approximately 50% of all bladder cancers are non-invasive or in situ cancers. Patients with high-risk, Non-Muscle Invasive Bladder Cancer that has become unresponsive to BCG (Bacillus Calmette-Guerin) treatment, are often given the treatment option of radical cystectomy, which includes removing the entire urinary bladder and a prostatectomy for men or total hysterectomy in women. While highly curative, this surgical procedure carries substantial risk for morbidity and mortality, and can negatively impact patient’s quality of life. Further, a significant proportion of patients are medically ineligible for a radical cystectomy, and even if eligible, refuse surgery and opt for other less effective treatments, which could compromise outcomes.

KEYTRUDA® (Pembrolizumab) is a fully humanized, Immunoglobulin G4, anti-PD-1, monoclonal antibody, that binds to the PD-1 receptor and blocks its interaction with ligands PD-L1 and PD-L2. By doing so, it unleashes the tumor-specific effector T cells, and is thereby able to undo PD-1 pathway-mediated inhibition of the immune response. KEYTRUDA® is presently approved by the FDA for the treatment of patients with locally advanced or metastatic Urothelial carcinoma who are not eligible for Cisplatin-containing chemotherapy or for those with disease progression during or following platinum-containing chemotherapy, based on its durable antitumor activity in this patient group. Upregulation of the PD-1 pathway has been observed in BCG-resistant NMIBC, suggesting that KEYTRUDA® may be of benefit in this group of patients. The FDA in 2020, approved KEYTRUDA® for the treatment of patients with BCG-unresponsive, high-risk, Non-Muscle Invasive Bladder Cancer (NMIBC) with Carcinoma In Situ (CIS) with or without papillary tumors, who are ineligible for or have elected not to undergo cystectomy, based on the KEYNOTE-057 study.

KEYNOTE-057 study is an international, multicenter, single arm, open-label, Phase II trial that enrolled 101 eligible patients with high-risk NMIBC, who had BCG-unresponsive CIS with or without papillary tumors. BCG-unresponsive high-risk Non-Muscle Invasive Bladder Cancer was defined as persistent disease despite adequate BCG therapy, disease recurrence after an initial tumor-free state following adequate BCG therapy, or T1 disease following a single induction course of BCG. Eligible patients had received adequate BCG therapy and were unable/unwilling to undergo radical cystectomy. All patients had undergone TransUrethral Resection of Bladder Tumor (TURBT) to remove resectable disease. Patients with residual Carcinoma In Situ, not amenable to complete resection were permitted. Patients received KEYTRUDA® 200 mg IV every 3 weeks until unacceptable toxicity, persistent or recurrent high-risk NMIBC or progressive disease, or up to 24 months of therapy without disease progression. The efficacy analysis included 96 patients, as 5 patients did not meet the FDA BCG-unresponsive criteria.

The median age was 73 years and the median number of prior BCG instillations was 12. More than half of patients (56.9%) had a PD-L1 Combined Positive Score (CPS) of less than 10, and most patients in this analysis had refused prior cystectomy. The Primary end point was Complete Response Rate (CRR-absence of high-risk non-muscle invasive bladder cancer or progressive disease) as defined by negative results for cystoscopy with TURBT/biopsies as applicable, urine cytology, and CT Urography imaging, approximately 3 months after the first dose of KEYTRUDA®. Secondary end points included Duration of Response and Safety.

At a median follow up of 36.4 months, the Complete Response Rate at 3 months was 41% and the median Duration of Response was 16.2 months. Forty-six percent (46%) of responding patients experienced a Complete Response lasting 12 months or more. The Complete Response Rate was consistent with the primary analysis across protocol-prespecified subgroups, including PD-L1 expression status. The most frequent adverse reactions were fatigue, diarrhea, rash, pruritis, arthralgia, musculoskeletal pain, peripheral edema and hypothyroidism.

It was concluded that with extended follow up, KEYTRUDA® monotherapy continued to show durable and clinically meaningful antitumor activity in patients with high risk BCG-unresponsive, non-muscle invasive bladder cancer, who declined or were ineligible for radical cystectomy. The authors added that KEYTRUDA® should be considered a clinically active non-surgical treatment option in this difficult-to-treat population.

Pembrolizumab monotherapy for the treatment of high-risk non-muscle-invasive bladder cancer unresponsive to BCG (KEYNOTE-057): an open-label, single-arm, multicentre, phase 2 study. Balar AV, Kamat AM, Kulkarni GS, et al. The Lancet Oncology. 2021;22:919-930.

FDA Approves TRODELVY® for Advanced Urothelial Cancer

SUMMARY: The FDA on April 13, 2021, granted accelerated approval to TRODELVY® (Sacituzumab Govitecan) for patients with locally advanced or metastatic Urothelial Cancer who previously received a Platinum-containing chemotherapy, and either a Programmed Death receptor-1 (PD-1) or a Programmed Death-Ligand 1 (PD-L1) inhibitor. The American Cancer Society estimates that in the United States for 2021, about 83,730 new cases of bladder cancer will be diagnosed and approximately 17,200 patients will die of the disease. Bladder cancer is the fourth most common cancer in men, but it is less common in women. A third of the patients initially present with locally invasive or metastatic disease. Patients with Urothelial Carcinoma are currently treated in the first line setting with a Platinum based chemotherapy regimen, and a checkpoint Inhibitor (PD-1 or PD-L1 inhibitor) in the second line setting. Treatment options for patients who progress after first and second line therapies are limited, with poor outcomes. The response rates with standard chemotherapy in this patient population, is about 10%, with a median Overall Survival (OS) of 7-8 months.

Two new agents approved by the FDA include BALVERSA® (Erdafitinib), a pan-Fibroblast Growth Factor Receptor (FGFR) inhibitor, for patients with locally advanced or metastatic Urothelial Carcinoma with susceptible FGFR3 or FGFR2 genetic alterations, that has progressed during or following Platinum-containing chemotherapy, as well as PADCEV® (Enfortumab Vedotin), an Antibody-Drug Conjugate (ADC) that targets Nectin-4, a cell adhesion molecule, highly expressed in Urothelial Cancers and other solid tumors. These two agents have Objective Response Rates (ORRs) of approximately 40%, and most patients will progress on these therapies. Further, FGFR alterations occur in only 20% of patients with metastatic Urothelial Carcinoma, limiting the use of BALVERSA®. Hence, there is an unmet need for novel therapies.

Trop-2 is a transmembrane glycoprotein and calcium signal transducer. It stimulates cancer-cell growth, and this cell surface receptor is overexpressed in several epithelial cancers including cancers of the Breast, Colon, Lung and Urothelial Cancer, and has limited expression in normal human tissues. TRODELVY® is an Antibody-Drug Conjugate (ADC) in which SN-38, an active metabolite of Irinotecan, a Topoisomerase I inhibitor, is coupled to the humanized Anti-Trophoblast cell-surface antigen 2 (Trop-2) monoclonal antibody (hRS7 IgG1κ), through the cleavable CL2A linker. SN-38 cannot be given directly to patients because of its toxicity and poor solubility. Upon binding to Trop-2, the anti-TROP-2 monoclonal antibody is internalized and delivers SN-38 directly into the tumor cell, making it a suitable transporter for the delivery of cytotoxic drugs. Further, the cleavable linker enables SN-38 to be released both intracellularly into the tumor cells, as well as the tumor microenvironment, thereby allowing for the delivery of therapeutic concentrations of the active drug in bystander cells to which the conjugate has not bound. Thus, TRODELVY®-bound tumor cells are killed by intracellular uptake of SN-38, whereas the adjacent tumor cells are killed by the extracellular release of SN-38.

TRODELVY® in a Phase I/II trial involving patients with advanced epithelial cancers, showed encouraging clinical activity across various solid tumors and was associated with a Objective Response Rate (ORR) of 31% in patients with relapsed or refractory metastatic Urothelial Carcinoma, including a 27% ORR among patients who had received prior checkpoint inhibitor and Platinum based therapy. The TROPHY-U-01 Phase II trial was designed to assess the activity of TRODELVY® and confirm these findings in patients with locally advanced unresectable or metastatic Urothelial Carcinoma. This trial includes 5 patient cohorts, evaluating the role of TRODELVY® in various groups of patients and in combination with various agents including checkpoint inhibitors. The authors in this publication reported the primary results from the full Cohort 1 of the TROPHY-U-01 study in patients with metastatic Urothelial Cancer who progressed after prior Platinum based and checkpoint inhibitor based therapies.

Cohort 1 included 113 patients who had received a median of three prior therapies. Patients received TRODELVY® 10 mg/kg IV, on days 1 and 8 of a 21-day treatment cycle, until disease progression or unacceptable toxicities. The median patient age was 66 years and 66% of patients had visceral metastases. The main efficacy endpoints were Objective Response Rate (ORR) and Duration of Response (DOR), evaluated by Independent Review, using RECIST 1.1 criteria.

At a median follow up of 9.1 months, the ORR was 27.7%, and 77% of patients had decrease in measurable disease. The Complete Response rate was 5.4% and 22.3% had Partial Responses. The median DOR was 7.2 months. The median Progression Free Survival was 5.4 months and Overall Survival was 10.9 months. Important Grade 3 or more treatment related adverse events included, neutropenia, anemia, diarrhea, and febrile neutropenia, with 6% of patients discontinuing treatment due to adverse events because of treatment-related adverse events.

It was concluded that TRODELVY® is an active agent and has notable efficacy, compared with historical controls, in pretreated metastatic Urothelial Cancer, that has progressed on both prior Platinum regimens and checkpoint inhibitors, and has manageable safety profile.

TROPHY-U-01: A Phase II Open-Label Study of Sacituzumab Govitecan in Patients With Metastatic Urothelial Carcinoma Progressing After Platinum-Based Chemotherapy and Checkpoint Inhibitors. Tagawa, ST, Balar AV, Petrylak DP, et al. J Clin Oncol. 2021;39:2474-2485.

PADCEV® (Enfortumab Vedotin-ejfv)

The FDA on July 9, 2021 approved PADCEV®, a Nectin-4-directed antibody and microtubule inhibitor conjugate, for adult patients with locally advanced or metastatic urothelial cancer who

  • have previously received a Programmed Death receptor-1 (PD-1) or Programmed Death-Ligand (PD-L1) inhibitor and Platinum-containing chemotherapy, or
  • are ineligible for Cisplatin-containing chemotherapy and have previously received one or more prior lines of therapy.

PADCEV® is a product of Astellas Pharma US, Inc.

Adjuvant Treatment with OPDIVO® in Muscle-Invasive Urothelial Carcinoma

SUMMARY: The American Cancer Society estimates that in the United States for 2021, about 83,730 new cases of bladder cancer will be diagnosed and approximately 17,200 patients will die of the disease. Bladder cancer is the fourth most common cancer in men, but it is less common in women. A third of the patients initially present with locally invasive or metastatic disease. Even though radical cystectomy is considered the standard of care for patients with localized Muscle Invasive Bladder Cancer (MIBC), two large randomized trials and two meta-analysis have shown greater survival benefit with neoadjuvant Cisplatin-based combination chemotherapy for patients with MIBC, compared to surgery alone. However, not all patients with MIBC benefit from neoadjuvant Cisplatin based therapy, with only 25-50% attaining a pathologic response. More than 50% of patients with MIBC or regional lymph node involvement will develop metastatic disease following radical cystectomy. There is presently no clear consensus with regards to the routine use of adjuvant Cisplatin-based chemotherapy. Further, not all patients are eligible for adjuvant or neoadjuvant Cisplatin-based chemotherapy.

OPDIVO® (Nivolumab) is a fully human, immunoglobulin G4 monoclonal antibody that binds to the PD-1 receptor and blocks its interaction with PD-L1 and PD-L2. Blocking the Immune checkpoint proteins unleashes the T cells, resulting in T cell proliferation, activation and a therapeutic response. OPDIVO® has been shown to have antitumor activity in patients with metastatic urothelial carcinoma who had previously received platinum treatment, and is presently approved by the FDA for this patient group.

CheckMate 274 is a multicenter, double-blind, randomized, Phase III trial conducted to evaluate the efficacy and safety of adjuvant OPDIVO®, as compared with placebo, in patients with muscle-invasive urothelial carcinoma following radical surgery (with or without previous neoadjuvant Cisplatin-based combination chemotherapy). A total of 709 patients with muscle-invasive urothelial carcinoma who had undergone radical surgery were randomly assigned in a 1:1 ratio to receive either OPDIVO® 240 mg as a 30-minute IV infusion (N=353) or placebo (N=356), every 2 weeks for up to 1 year. To be eligible, patients must have had radical surgery (R0, with negative surgical margins), with or without neoadjuvant Cisplatin-based chemotherapy. Patients must have had pathological evidence of urothelial carcinoma (originating in the bladder, ureter or renal pelvis) with a high risk of recurrence defined as follows: pathological stage of pT3, pT4a, or pN+ and patients not eligible for or declined adjuvant Cisplatin-based combination chemotherapy, patients who had not received neoadjuvant Cisplatin-based chemotherapy, and pathological stage of ypT2 to ypT4a or ypN+ for patients who received neoadjuvant Cisplatin. Both treatment groups were well balanced and approximately 40% of patients in both treatment groups had PD-L1 expression of 1% or more and 43% of patients had received previous neoadjuvant cisplatin therapy. The two Primary endpoints were Disease Free Survival (DFS) among all the patients, and among patients with a tumor Programmed Death-Ligand 1 (PD-L1) expression level of 1% or more. Secondary endpoints included Survival free from recurrence outside the urothelial tract, Overall Survival and Safety. The median follow up was 20.9 months among patients who received OPDIVO® and 19.5 months among those who received placebo.

The median DFS was 20.8 months in the OPDIVO® group and 10.8 months in the placebo group in the intention-to-treat population, which was nearly double that with placebo. The percentage of patients who were alive and disease-free at 6 months was 74.9% with OPDIVO® and 60.3% with placebo, in the intention-to-treat population (HR for disease recurrence or death=0.70; P<0.001). Among patients with a PD-L1 expression level of 1% or more, the percentage who were alive and disease-free at 6 months was 74.5% with OPDIVO® and 55.7% with placebo, in the Intention-to-Treat Population (HR=0.55; P<0.001). The subgroup analysis showed that there was a higher probability of DFS with OPDIVO® than with placebo, and this benefit was observed regardless of nodal status, PD-L1 status, or use or nonuse of previous neoadjuvant Cisplatin-based chemotherapy.

The median survival free from recurrence outside the urothelial tract, in the intention-to-treat population, was 22.9 months among patients who received OPDIVO® and 13.7 months with placebo. The percentage of patients who were alive and free from recurrence outside the urothelial tract at 6 months was 77% with OPDIVO® and 62.7% with placebo (HR for recurrence outside the urothelial tract or death=0.72). Among those with a PD-L1 expression level of 1% or more, the percentage who were alive and free from recurrence outside the urothelial tract at 6 months was 75.3% and 56.7%, respectively (HR=0.55). Grade 3 or higher toxicities were noted in 17.9% of patients in the OPDIVO® group and 7.2% of patients in the placebo group.

It was concluded that among patients with high risk muscle-invasive urothelial carcinoma who had undergone radical surgery with curative intent, adjuvant treatment with OPDIVO® significantly improved Disease Free Survival, compared to placebo, in both intention-to-treat population and among patients with a PD-L1 expression level of 1% or more.

Adjuvant Nivolumab versus Placebo in Muscle-Invasive Urothelial Carcinoma. Bajorin DF, Witjes JA, Gschwend JE, et al. N Engl J Med 2021;384:2102-2114.

PADCEV® Prolongs Overall Survival in Metastatic Urothelial Carcinoma

SUMMARY: The American Cancer Society estimates that in 2021, approximately 83,730 new cases of Bladder Cancer will be diagnosed and 17,200 patients will die of the disease. Patients with urothelial carcinoma are currently treated in the first line setting with a Platinum based chemotherapy regimen and a checkpoint Inhibitor (PD-1 or PD-L1 inhibitor) in the second line setting. Treatment options for patients who progress after first and second line therapies are limited, with poor outcomes. The response rates with standard chemotherapy in this patient population, is about 10%.

PADCEV® (Enfortumab vedotin-ejfv) is an Antibody-Drug Conjugate (ADC) that targets Nectin-4, a cell adhesion molecule highly expressed in urothelial cancers and other solid tumors. Nectin-4 has been implicated in tumor cell growth and proliferation. Following binding to Nectin-4 on the cell surface, PADCEV® becomes internalized and is processed by lysosomes, with the liberation of its cytotoxic payload, Monomethyl auristatin E, which in turn disrupts microtubule assembly, leading to cell cycle arrest and apoptosis. The FDA in 2019 granted accelerated approval to PADCEV® for adult patients with locally advanced or metastatic urothelial cancer, who have previously received a Programmed Death receptor-1 (PD-1) or Programmed Death-Ligand1 (PD-L1) inhibitor, and a Platinum-containing chemotherapy in the neoadjuvant/adjuvant, locally advanced or metastatic setting. This approval was based on the results from the pivotal Phase II EV-201 study which concluded that treatment with PADCEV® demonstrated a clinically meaningful 44% Objective Response Rate (ORR) in this patient group. EV-301 study was designed to confirm the clinical benefit of PADCEV® as compared with standard chemotherapy, by assessing Overall Survival in patients with advanced urothelial carcinoma, who had previously received treatment.

EV-301 is a global, open-label, randomized, Phase III trial, that evaluated the efficacy of PADCEV®, as compared with chemotherapy, in patients with locally advanced or metastatic urothelial carcinoma, who had previously received treatment with a platinum-based chemotherapy and a PD-1 or PD-L1 inhibitor. A total of 608 patients were randomly assigned 1:1 to receive either PADCEV® 1.25 mg/kg IV on days 1, 8, and 15 of a 28-day cycle (N=301), or investigator choice of chemotherapy (Docetaxel 75 mg/m2 IV, Paclitaxel 175 mg/m2 IV, or Vinflunine 320 mg/m2 IV, administered on day 1 of a 21-day cycle (N=307). Both treatment groups were well balanced. The median patient age was 68 years, about 79% of patients had visceral metastases, and 69% of patients had no response to previous treatment with checkpoint inhibitor. The Primary end point was Overall Survival (OS). Secondary end points included Progression Free Survival (PFS) and Overall Response Rate (ORR) and Safety. At the prespecified interim analysis, the median follow up was 11.1 months.

The median OS was 12.88 months in the PADCEV® group versus 8.97 months in patients treated with chemotherapy (H= 0.70; P=0.001), suggesting a 30% reduction in the risk of death with PADCEV®. The PFS was also longer in the PADCEV® group, and was 5.6 months versus 3.7 months with chemotherapy (HR=0.62; P<0.001). The confirmed ORR was higher in the PADCEV® group than in the chemotherapy group (40.6% versus 17.9%; P<0.001), and a Complete Response was observed in 4.9% of the patients in the PADCEV® group and in 2.7% of the patients in the chemotherapy group. Disease Control Rate was 71.9% and 53.4%, respectively (P<0.001). Treatment-related Adverse Events were similar in the two treatment groups.

The authors concluded that treatment with PADCEV® resulted in significantly longer Overall Survival, Progression Free Survival and a higher Overall Response Rate, than standard chemotherapy, in patients with locally advanced or metastatic urothelial carcinoma, who had previously received Platinum-based treatment and a PD-1 or PD-L1 inhibitor.

Enfortumab Vedotin in Previously Treated Advanced Urothelial Carcinoma. Powles T, Rosenberg JE, Sonpavde GP, et al. N Engl J Med 2021; DOI: 10.1056/NEJMoa2035807