Another area of interest is evaluating mutations in DNA repair genes that have an association with outcomes. A study presented at the 2016 American Society of Clinical Oncology (ASCO) Annual Meeting identified several DNA damage repair genes that may predict response to cisplatin-based chemotherapy including ERCC2, ERCC5, BRCA2, and RAD51C.8

“Practicing physicians, medical oncologists, radiation oncologists, and urologists all need to be aware of what is on the immediate horizon,” Dr Black said. “These markers could have a real clinical impact in the very near future.”

Radiotherapy & Immunotherapy

The final presentation of the session discussed how immunotherapy might be incorporated into radiation therapy in patients with bladder cancer. Patients who are unable or unwilling to undergo treatment with neoadjuvant chemotherapy plus radical cystectomy may be candidates for trimodal therapy with transurethral resection and radiochemotherapy.

Classically, radiation works by damaging DNA and causing double strand breaks that lead to cell death, explained Abhishek A. Solanki, MD, of Loyola University Chicago in Illinois.

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“New data suggest that radiation might also utilize the body’s immune system to kill cancer cells,” Dr Solanki said. “When the radiation damages cancer cells and kills it, that releases tumor antigens, and your body’s immune system discovers those antigens and activates the body’s response immune response against those cancer cells.”

There are ongoing studies evaluating whether immunotherapy can be used in combination with radiation to be more effective at killing cancer and vice versa. These studies are also evaluating the safety of combining these treatments.

“In bladder cancer, immunotherapy can cause colitis, an inflammation of the bowel, and radiation also poses a risk to damaging the bowel,” Dr Solanki said.

Until there are more data, immunotherapy and radiation should be used together only in clinical trials.

References

  1. Cancer stat facts: bladder cancer. National Cancer Institute website. https://seer.cancer.gov/statfacts/html/urinb.html. Accessed January 2018.
  2. FDA approves nivolumab for bladder cancer. National Cancer Institute website. https://www.cancer.gov/news-events/cancer-currents-blog/2017/fda-nivolumab-bladder. Published March 1, 2017. Accessed January 2018.
  3. FDA approves immunotherapy drugs for patients with bladder cancer. National Cancer Institute website. https://www.cancer.gov/news-events/cancer-currents-blog/2017/approvals-fda-checkpoint-bladder. Published May 30, 2017. Accessed January 2018.
  4. Treatment of non-metastatic muscle-invasive bladder cancer: AUA/ASCO/ASTRO/SUO guideline. American Urological Association website. http://www.auanet.org/guidelines/muscle-invasive-bladder-cancer-new-(2017). Published 2017. Accessed January 2018.
  5. Kothari S, Gustafson D, Killian K, et al. COXEN prediction of antineoplastic drug sensitivity in bladder cancer patients. J Clin Oncol. 2015;33(suppl 15):e15533.
  6. A randomized phase II study of Co-eXpression extrapolation (COXEN)-directed neoadjuvant chemotherapy for localized, muscle-invasive bladder cancer. SWOG website. https://www.swog.org/clinical-trials/s1314. Updated December 2017. Accessed January 2018.
  7. Seiler R, Winters B, Douglas J, et al. Muscle-invasive bladder cancer: molecular subtypes and response to neoadjuvant chemotherapy. J Clin Oncol. 2017;35(suppl 6):281.
  8. Evaluation of DNA damage repair genes may play role in tailoring genitourinary cancer treatment. American Society of Clinical Oncology website. https://am.asco.org/evaluation-dna-damage-repair-genes-may-play-role-tailoring-genitourinary-cancer-treatment. Published June 7, 2016. Accessed January 2018.