Advances in risk stratification of bladder cancer to guide personalized medicine

Justin T Matulay, Ashish M Kamat, Justin T Matulay, Ashish M Kamat

Abstract

Bladder cancer is a heterogeneous disease that poses unique challenges to the treating clinician. It can be limited to a relatively indolent papillary tumor with low potential for progression beyond this stage to muscle-invasive disease prone to distant metastasis. The former is best treated as conservatively as possible, whereas the latter requires aggressive surgical intervention with adjuvant therapies in order to provide the best clinical outcomes. Risk stratification traditionally uses clinicopathologic features of the disease to provide prognostic information that assists in choosing the best therapy for each individual patient. For bladder cancer, this informs decisions regarding the type of intravesical therapy that is most appropriate for non-muscle-invasive disease or whether or not to administer neoadjuvant chemotherapy prior to radical cystectomy. More recently, tumor genetic sequencing data have been married to clinical outcomes data to add further sophistication and personalization. In the next generation of risk classification, we are likely to see the inclusion of molecular subtyping with specific treatment considerations based on a tumor's mutational profile.

Keywords: Bladder cancer; bladder cancer genetics; personalized medicine; risk stratification; urothelial carcinoma.

Conflict of interest statement

Competing interests: AMK is a consultant to TMC Innovation, Merck, BMS, Arquer, MDxHealth, Photocure, Theralase, Cepheid, Medac, Asieris, Pfizer, and Astra Zeneca and has received research funding from FKD, Merck, Telesta, and Adolo. JTM has no competing interests to declare.No competing interests were disclosed.No competing interests were disclosed.No competing interests were disclosed.No competing interests were disclosed.

Figures

Figure 1.. Proposed substratification of intermediate-risk non-muscle-invasive…
Figure 1.. Proposed substratification of intermediate-risk non-muscle-invasive bladder cancer (NMIBC) based on the recommendations of the International Bladder Cancer Group .
BCG, bacillus Calmette-Guérin; TURBT, transurethral resection of bladder tumor.
Figure 2.. Molecular subtypes of muscle-invasive bladder…
Figure 2.. Molecular subtypes of muscle-invasive bladder cancer with associated clinicopathologic and genomic characteristics.
Proposed treatment considerations are listed for each subtype based on available clinical data – , , , – . CIS, carcinomain situ; CTLA-4, cytotoxic T-lymphocyte-associated antigen 4; DLX6, distal-less homeobox 6; E2F3, E2F transcription factor 3; EMT, epithelial to mesenchymal transition; FGFR3, fibroblast growth factor receptor 3; FOX, forkhead box; GATA, GATA-binding protein; KRT, keratin; miR-200, microRNA 200; msi1, Musashi homolog 1; PD-1, programmed death-1; PD-L1, programmed death-ligand 1; PLEKHG4B, pleckstrin homology and RhoGEF domain containing G4B; SHH, sonic hedgehog; SNX31, sorting nexin 31; SOX, SRY-box.
Figure 3.. Proposed decision model for immediate…
Figure 3.. Proposed decision model for immediate radical cystectomy in patients with “very high-risk” non-muscle-invasive bladder cancer (NMIBC) , – .
AUA, American Urological Association; BCG, bacillus Calmette-Guérin; CIS, carcinomain situ; LVI, lymphovascular invasion; TURBT, transurethral resection of bladder tumor.
Figure 4.. Current MD Anderson Cancer Center…
Figure 4.. Current MD Anderson Cancer Center algorithm for determining which patients should receive neoadjuvant chemotherapy versus immediate radical cystectomy.
Inclusion of molecular markers for further risk stratification is pending clinical validation . MIBC, muscle-invasive bladder cancer.

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    1. Shelley MD, Mason MD, Kynaston H: Intravesical therapy for superficial bladder cancer: a systematic review of randomised trials and meta-analyses. Cancer Treat Rev. 2010;36(3):195–205. 10.1016/j.ctrv.2009.12.005
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    1. Chou R, Selph S, Buckley DI, et al. : Intravesical Therapy for the Treatment of Nonmuscle Invasive Bladder Cancer: A Systematic Review and Meta-Analysis. J Urol. 2017;197(5):1189–99. 10.1016/j.juro.2016.12.090
    1. Brausi M, Oddens J, Sylvester R, et al. : Side effects of Bacillus Calmette-Guérin (BCG) in the treatment of intermediate- and high-risk Ta, T1 papillary carcinoma of the bladder: results of the EORTC genito-urinary cancers group randomised phase 3 study comparing one-third dose with full dose and 1 year with 3 years of maintenance BCG. Eur Urol. 2014;65(1):69–76. 10.1016/j.eururo.2013.07.021
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    1. Barlow LJ, Benson MC: Experience with newer intravesical chemotherapy for high-risk non-muscle-invasive bladder cancer. Curr Urol Rep. 2013;14(2):65–70. 10.1007/s11934-013-0312-2
    1. Di Lorenzo G, Perdonà S, Damiano R, et al. : Gemcitabine versus bacille Calmette-Guérin after initial bacille Calmette-Guérin failure in non-muscle-invasive bladder cancer: a multicenter prospective randomized trial. Cancer. 2010;116(8):1893–900. 10.1002/cncr.24914
    1. McKiernan JM, Holder DD, Ghandour RA, et al. : Phase II trial of intravesical nanoparticle albumin bound paclitaxel for the treatment of nonmuscle invasive urothelial carcinoma of the bladder after bacillus Calmette-Guérin treatment failure. J Urol. 2014;192(6):1633–8. 10.1016/j.juro.2014.06.084
    1. Porten SP, Leapman MS, Greene KL: Intravesical chemotherapy in non-muscle-invasive bladder cancer. Indian J Urol. 2015;31(4):297–303. 10.4103/0970-1591.166446
    1. Shelley MD, Jones G, Cleves A, et al. : Intravesical gemcitabine therapy for non-muscle invasive bladder cancer (NMIBC): a systematic review. BJU Int. 2012;109(4):496–505. 10.1111/j.1464-410X.2011.10880.x
    1. Steinberg G, Bahnson R, Brosman S, et al. : Efficacy and safety of valrubicin for the treatment of Bacillus Calmette-Guerin refractory carcinoma in situ of the bladder. The Valrubicin Study Group. J Urol. 2000;163(3):761–7. 10.1016/S0022-5347(05)67799-3
    1. Sternberg IA, Dalbagni G, Chen LY, et al. : Intravesical gemcitabine for high risk, nonmuscle invasive bladder cancer after bacillus Calmette-Guérin treatment failure. J Urol. 2013;190(5):1686–91. 10.1016/j.juro.2013.04.120
    1. Mathieu R, Lucca I, Rouprêt M, et al. : The prognostic role of lymphovascular invasion in urothelial carcinoma of the bladder. Nat Rev Urol. 2016;13(8):471–9. 10.1038/nrurol.2016.126
    1. Martin-Doyle W, Leow JJ, Orsola A, et al. : Improving selection criteria for early cystectomy in high-grade t1 bladder cancer: a meta-analysis of 15,215 patients. J Clin Oncol. 2015;33(6):643–50. 10.1200/JCO.2014.57.6967

    2. F1000 Recommendation

    1. Willis DL, Fernandez MI, Dickstein RJ, et al. : Clinical outcomes of cT1 micropapillary bladder cancer. J Urol. 2015;193(4):1129–34. 10.1016/j.juro.2014.09.092
    1. Segal R, Yafi FA, Brimo F, et al. : Prognostic factors and outcome in patients with T1 high-grade bladder cancer: can we identify patients for early cystectomy? BJU Int. 2012;109(7):1026–30. 10.1111/j.1464-410X.2011.10462.x
    1. Mally AD, Tin AL, Lee JK, et al. : Clinical Outcomes of Patients With T1 Nested Variant of Urothelial Carcinoma Compared to Pure Urothelial Carcinoma of the Bladder. Clin Genitourin Cancer. 2017; pii: S1558-7673(17)30199-4. 10.1016/j.clgc.2017.07.002
    1. Ark JT, Keegan KA, Barocas DA, et al. : Incidence and predictors of understaging in patients with clinical T1 urothelial carcinoma undergoing radical cystectomy. BJU Int. 2014;113(6):894–9. 10.1111/bju.12245
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    1. Choudhury A, Nelson LD, Teo MT, et al. : MRE11 expression is predictive of cause-specific survival following radical radiotherapy for muscle-invasive bladder cancer. Cancer Res. 2010;70(18):7017–26. 10.1158/0008-5472.CAN-10-1202
    1. Laurberg JR, Brems-Eskildsen AS, Nordentoft I, et al. : Expression of TIP60 (tat-interactive protein) and MRE11 (meiotic recombination 11 homolog) predict treatment-specific outcome of localised invasive bladder cancer. BJU Int. 2012;110(11 Pt C):E1228–36. 10.1111/j.1464-410X.2012.11564.x
    1. Grossman HB, Natale RB, Tangen CM, et al. : Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med. 2003;349(9):859–66. 10.1056/NEJMoa022148

    2. F1000 Recommendation

    1. Advanced Bladder Cancer (ABC) Meta-analysis Collaboration: Neoadjuvant chemotherapy in invasive bladder cancer: update of a systematic review and meta-analysis of individual patient data advanced bladder cancer (ABC) meta-analysis collaboration. Eur Urol. 2005;48(2):202–5; discussion 205–6. 10.1016/j.eururo.2005.04.006
    1. Yuh BE, Ruel N, Wilson TG, et al. : Pooled analysis of clinical outcomes with neoadjuvant cisplatin and gemcitabine chemotherapy for muscle invasive bladder cancer. J Urol. 2013;189(5):1682–6. 10.1016/j.juro.2012.10.120
    1. International Collaboration of Trialists, Medical Research Council Advanced Bladder Cancer Working Party (now the National Cancer Research Institute Bladder Cancer Clinical Studies Group), European Organisation for Research and Treatment of Cancer Genito-Urinary Tract Cancer Group, et al. : International phase III trial assessing neoadjuvant cisplatin, methotrexate, and vinblastine chemotherapy for muscle-invasive bladder cancer: long-term results of the BA06 30894 trial. J Clin Oncol. 2011;29(16):2171–7. 10.1200/JCO.2010.32.3139

    2. F1000 Recommendation

    1. Culp SH, Dickstein RJ, Grossman HB, et al. : Refining patient selection for neoadjuvant chemotherapy before radical cystectomy. J Urol. 2014;191(1):40–7. 10.1016/j.juro.2013.07.061
    1. Moschini M, Soria F, Klatte T, et al. : Validation of Preoperative Risk Grouping of the Selection of Patients Most Likely to Benefit From Neoadjuvant Chemotherapy Before Radical Cystectomy. Clin Genitourin Cancer. 2017;15(2):e267–e273. 10.1016/j.clgc.2016.07.014

    2. F1000 Recommendation

    1. Sternberg CN, Skoneczna I, Kerst JM, et al. : Immediate versus deferred chemotherapy after radical cystectomy in patients with pT3-pT4 or N+ M0 urothelial carcinoma of the bladder (EORTC 30994): an intergroup, open-label, randomised phase 3 trial. Lancet Oncol. 2015;16(1):76–86. 10.1016/S1470-2045(14)71160-X

    2. F1000 Recommendation

    1. Dong F, Shen Y, Gao F, et al. : Nomograms to Predict Individual Prognosis of Patients with Primary Small Cell Carcinoma of the Bladder. J Cancer. 2018;9(7):1152–64. 10.7150/jca.23344
    1. Kouba EJ, Cheng L: Understanding the Genetic Landscape of Small Cell Carcinoma of the Urinary Bladder and Implications for Diagnosis, Prognosis, and Treatment: A Review. JAMA Oncol. 2017;3(11):1570–8. 10.1001/jamaoncol.2016.7013
    1. Millis SZ, Bryant D, Basu G, et al. : Molecular profiling of infiltrating urothelial carcinoma of bladder and nonbladder origin. Clin Genitourin Cancer. 2015;13(1):e37–49. 10.1016/j.clgc.2014.07.010
    1. Zheng X, Liu D, Fallon JT, et al. : Distinct genetic alterations in small cell carcinoma from different anatomic sites. Exp Hematol Oncol. 2015;4:2. 10.1186/2162-3619-4-2
    1. Siefker-Radtke AO, Kamat AM, Grossman HB, et al. : Phase II clinical trial of neoadjuvant alternating doublet chemotherapy with ifosfamide/doxorubicin and etoposide/cisplatin in small-cell urothelial cancer. J Clin Oncol. 2009;27(16):2592–7. 10.1200/JCO.2008.19.0256

Source: PubMed

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