Immunotherapy in non-metastatic urothelial cancer: back to the ‘future’

ABSTRACT

Introduction: Successful results of immuno-oncological drugs in metastatic urothelial cancer have triggered the interest of researchers to test them in the non-metastatic setting. Conventional treatment modalities in that space are limited, sometimes toxic and with no improvement seen for the last 20 years and beyond. For patients failing intravesical BCG and mitomycin C in non-muscle invasive bladder cancer, no effective therapeutic alternatives exist besides cystectomy. In the neoadjuvant setting, cisplatin-based chemotherapy provides limited benefit in terms of disease recurrence and metastases, at the expense of toxic effects. The good news is that preliminary studies are showing great promise with the use of immunotherapy in the local and loco-regional disease. Larger studies are now on the way to confirm the exciting potential benefits of immunotherapy in this direction.

Areas covered: This review presents an overview of developments happening on the introduction of immunotherapy in non-metastatic urothelial cancer treatment.

Expert opinion: Immunotherapy in the non-metastatic disease setting in urothelial cancer is evolving. Early results tend to anticipate a predominant role in coming times. Large comparative trials are in progress to gather robust practice-changing evidence to bring a paradigm shift in the treatment landscape.

KEYWORDS:

• Adjuvant
• biomarkers
• bladder cancer
• immunotherapy
• MIBC
• neoadjuvant
• NMIBC
• radical cystectomy
• urothelial cancer

Article highlights

• There is a need of better options with more local and systemic efficacy in BCG naive and BCG failed patients, in NMIBC

• Worse oncological outcomes for patients with residual cancer at RC, in MIBC, offers unique potential opportunity to test adjuvant immunotherapy

• Despite the best of the efforts, in both RC or bladder-sparing approaches, the 5-year survival is 35-50%. Strategies to improve overall prognosis as well as to reduce the indications of RC are desperately needed

• A few completed studies and a number of ongoing studies on immunotherapy in nonmetastatic bladder cancer anticipate better outcomes and lesser toxicity than conventional treatment modalities

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper is not funded.