SUO 2018: The Case for Adjuvant Immunotherapy

Phoenix, Arizona ( Dr. Steinberg began his talk by highlighting all the FDA approved checkpoint inhibitor therapies in metastatic urothelial cancer following cisplatin. The use of immune-oncology (IO) agents has revolutionized the management of patients with locally advanced, unresectable, and metastatic urothelial carcinoma. Antibodies directed against the checkpoints ‘programmed cell death 1’ (PD-1) and ‘programmed death ligand 1’ (PD-L1) were shown to induce rapid and durable responses in advanced urothelial in the salvage setting and for patients in the first line-setting who are cisplatin-ineligible. These remarkable findings altered the treatment landscape and led to the FDA approval of five IO agents (atezolizumab, avelumab, durvalumab, nivolumab, pembrolizumab) in the platinum-resistant setting. 

Dr. Steinberg then highlighted the theoretical arguments in favor of neoadjuvant immunotherapy which includes that patients may not be fit enough to receive adjuvant IO agents after radical cystectomy (RC), but this hypothesis has been extrapolated from adjuvant cisplatin setting. On the contrary, IO agents are much less toxic, and patients are likely to tolerate it after RC. By using adjuvant IO agents, because of accurate staging and sequencing of the tumor, we can avoid overtreatment and select patients that are most in need of the benefit. Even though the side effects profile is better than cisplatin, we can potentially avoid them in patients who do not need any additional treatment after RC. IO agents are also expensive and should be used judiciously. There is level 1 data in melanoma, renal and lung cancer supporting the use of adjuvant IO agent and the recurrence-free survival is even more pronounced when the PD-L1 expression is higher. He then highlighted the adjuvant IO agent ongoing trials in bladder cancer- IMVigor010 which is closed to accrual, Checkmate 274 and AMBASSADOR. The results from these trials will help shed some more light on this specific research question.

Dr. Steinberg then concluded his talk by presenting some of the novel work that is ongoing at the University of Chicago with EpiVax oncology which is a vaccine company. EpiVax has developed AncerTM- an integrated and streamlined neo-epitope selection pipeline, that accelerates the selection of both CD4 and CD8 T cell neo-epitopes from sequencing data. The goal is to develop a personalized vaccine in combination with IO agents in the adjuvant setting for high-risk patients.

Presented by: Gary D. Steinberg, MD, University of Chicago Medical Center, Chicago, Illinois 

Written by: Abhishek Srivastava, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Fox Chase Cancer Center, Philadelphia, Pennsylvania, @shekabhishek, at the 19th Annual Meeting of the Society of Urologic Oncology (SUO), November 28-30, 2018 – Phoenix, Arizona