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Commentary on Science, Innovation & New Products with a focus on Oncology, Hematology & Cancer Immunotherapy

Posts from the ‘Bladder’ category

national-harbor-sunset

National Harbor, MD

Bladder cancer is the most common of the urothelial cancers and is the 9th most common cancer globally, with over 400,000 new cases each year and around 165,000 deaths. In the US, approximately 76,000 Americans will be diagnosed with bladder cancer in 2016 and ~11% of new diagnoses are made when bladder cancer is in advanced stages.

Unlike tumour types such as ovarian and pancreatic cancers, the majority of bladder and urothelial cancers are diagnosed at an earlier stage. The rates of recurrence and disease progression, however, are high and approx. 78% will recur within 5 years while the 5-year survival for stage IV bladder cancer is pretty dismal at 15%.

Earlier this year, Genentech/Roche’s anti-PDL1 antibody atezolizumab (Tecentriq) was approved by the FDA in the second line setting and was the first such new approval in this disease for 30 years.

Since then, there has been heightened interest in urothelial and bladder cancers in multiple settings, with several companies rushing to play catch up, including Merck and BMS.

We’ve been following the steady progress of checkpoint blockade this year at AACR, ASCO, ESMO and now SITC – amazingly, what was once a graveyard for Pharmaland has now become a hypercompetitive niche in a very short time.

Here, we take a look at the latest data in advanced urothelial cancers and explore the landscape in the context of rapidly increasing competition.

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Crowds of People at ASCO 2016

The ASCO Wall 2016

There has been much frustration on many fronts at the number of trials that do not see a relationship between PD-L1 expression and response. Some do, but many don’t. This has lead to quite a few investigators suggesting that the IHC assay may not be as useful as originally hoped, for predicting response to checkpoint blockade or selecting patients for therapy.

While we often do see a trend for more responders with higher levels of expression, the main issue is that PD-L1-negative patients can also see some responses, albeit at a lower rate.

There are many factors that can affect the measurement:

  • Fresh vs. archival tissue
  • Heterogeneity within the tumour
  • Tumour cells (TC) vs. immune cells (IC)
  • Different antibodies used for each assay
  • The dynamic nature of the tumour microenvironment – does timing of the biopsy matter?
  • Human error – a pathologist has to eyeball the IHC readouts and decide the level of staining intensity

And so on. These are just a few examples of the factors that can potentially affect the results, making it quite a challenging test to undertake. There is also time – does the level of expression vary temporally depending on which prior therapies are administered?

It would be easy to be disheartened by this, but fear not!

There were some impressive new data presented at ASCO that were not only intriguing, but also show us a way forward on how a multi-factorial approach could be used in different tumour types. By this I mean we might end up with different tests used in conjunction for several different cancers in order to a) predict responders and non-responders and b) better select patients for appropriate regimens or clinical trials.

It’s not going to be as easy as one size (or test) fits all.  Sometimes a more more sophisticated approach will be needed.  New data at ASCO gave us hints on what’s to come in this direction.

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One of the exciting developments in metastatic urothelial carcers of late has been the emergence of checkpoint blockade with some very encouraging signs of durable clinical activity. Urothelial cancers comprise a group of urinary tract tumours including bladder, penile, ureter etc, although most trials tend to enroll bladder cancer patients, where there is a high unmet medical need.

Chicago John Hancock Center View

View from the 95th floor of the John Hancock Center, Chicago

This year alone has seen the FDA grant AstraZeneca with breakthrough therapy designation for durvalumab in February, while Genentech/Roche subsequently received approval for atezolizumab (Tecentriq) based on phase 2 data on May 18th.

To put these developments in context, the last FDA approval in metastatic urothelial carcinoma was almost 4 decades ago in 1978 for the chemotherapy cisplatin!

As is often the case in Pharmaland, once one company starts exploring a therapy in a given tumour type, others will quickly follow. Already we have several immunotherapy agents being evaluated in urothelial carcinoma both in early and metastatic disease, so what can we learn from the data presented at ASCO last week and where is the landscape going in the future?

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Streets of San FranciscoOne of the interesting immuno-oncology presentations at the recent ASCO Genitourinary Cancers Symposium held in San Francisco from Jan 7 – 9, 2016 was presented by Dr Matt Galsky (Mount Sinai, New York).

Dr Galsky presented the results of a phase II trial of gemcitabine plus cisplatin plus ipilimumab in patients with metastatic urothelial cancer: HCRN GU-148 (Abstract 357).

The trial failed to reach its primary endpoint of showing a 20% increase in 1 year overall survival by the addition of ipilimumab compared to historical data for Gem + Cis in this patient population.

Many in the media don’t write up what is in essence “negative” data, but this trial is highly informative for those with an interest in urothelial cancer and in the optimal strategy for cancer immunotherapy. The GU16 discussant Dr Elizabeth Plimack (Fox Chase) raised many questions that merit consideration by those in the field.

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LONDON – atezolizumab (Roche/Genentech) is expected to change the standard of care (SOC) for the treatment of metastatic urothelial bladder cancer. That’s the key message I took from a recent interview with Professor Tom Powles (Barts Cancer Institute) on the role checkpoint inhibitors and cancer immunotherapy will play in the treatment of bladder cancer.

Professor Tom Powles BartsReaders will recall the compelling early phase 1 clinical trial data for atezolizumab (formerly MPDL3280A) that Prof Powles (pictured right) presented just over a year ago at the 2014 ASCO annual meeting: “Making a difference in advanced bladder cancer

Although other checkpoint inhibitors are in bladder cancer trials, and we have written about the pembrolizumab (Merck) data first presented at ESMO 2014 (“Breathing New Life into Bladder Cancer Treatment), it is expected that atezolizumab will win the race to market in the US and be the first checkpoint inhibitor to gain FDA approval for the second-line treatment of advanced bladder cancer.

Atezolizumab received breakthrough therapy designation (BTD) in May 2014 from the US Food and Drug Administration for PD-L1 positive metastatic urothelial bladder cancer after progression or intolerance of platinum based chemotherapy.

Earlier this summer Genentech announced in a press release that the IMvigor 210 phase 2 study was positive and met it’s primary endpoint, with a greater response rate associated with higher levels of PD-L1 expression.

European Cancer Congress 2015This data will be presented on Sunday Sept 27 as a late-breaker at the forthcoming 2015 European Cancer Congress in Vienna (Twitter #ECC2015), the European equivalent of the ASCO annual meeting organized in alternate years by ECCO and ESMO:

Atezolizumab in patients (pts) with locally-advanced or metastatic urothelial carcinoma (mUC): Results from a pivotal multicenter phase II study (IMvigor 210)

Although we won’t know the trial results until they are presented in Vienna by Dr Jonathan Rosenberg (MSKCC), based on the recent press release it’s widely expected that the positive data from this trial will lead to rapid regulatory approval in the United States.

Subscribers can login below or you can purchase access to read Prof Powles’ opinion on the role checkpoint inhibitors will play in the treatment of bladder cancer, how this may play out in Europe as compared to the United States, and what the future may hold beyond checkpoint monotherapy.

This interview does not discuss the data to be presented at the 2015 European Cancer Congress, the results of which we will have to wait until Vienna to hear.

Gumbo Shop New OrleansThe annual meeting of the 2015 American Urological Assoication (AUA) is being held in New Orleans… Yes, we’re on the third and final leg of our Louisiana trip encompassing AAI, ASGCT and now the triumvirate of AUA-SBUR-SUO.

This morning, I attended the Urologic Oncology Research Symposium, “High impact science in urologic oncology and progress in biomedical imaging.”  In particular, I was keen to hear about the latest research in urothelial bladder cancer (UBC) with regards to checkpoint blockade with anti-PDL1 and PD-1 therapies.

In the past, any session on bladder cancer guaranteed the lucky (or hapless) presenters with an audience of a dozen or so people.  Not any more – the room was packed with standing room only very quickly – a nice change for a disease that has seen no new therapies for 30 years.

Part of this renewed enthusiasm is due to the excitement for the checkpoint therapies making a huge impact in this disease, at least in clinical trials to date. While waiting for the session to start, one urologist I spoke to told me he bought the ASCO Virtual Meeting last year just to hear Dr Tom Powles talk on anti-PDL1 therapy with MPDL3280A in advanced urothelial cancer. What did you think of it, I asked?

“Wow, just wow!”

Later this month an update on the more mature data from that phase I trial is due at the American Society of Clinical Oncology (ASCO) from Dr Daniel Petrylak (Yale)… who just happened to be one of the presenters at AUA this morning.

He discussed the checkpoint data with atezolizumab (MPDL3280A) in urothelial bladder cancer, as well as the pembrolizumab data from ESMO last fall and what’s happening with nivolumab. These drugs are quite different in many ways, not just in terms of the efficacy, but also in terms of the biomarker data, as we discovered today.

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One of the obvious learnings from the American Association of Clinical Research (AACR) meeting earlier this week was that we are coming to the end of the low hanging fruit opportunities for checkpoint inhibitors as monotherapies.

Speaking with numerous company people in this space, there was wide consensus on that point. As one clinical lead put it succinctly, “From here on out, it’s going to get way more complicated – had a low grade headache develop after the very first science session I attended – and it’s still there after two days!”

How many of us know that feeling all too well?  AACR always has the heaviest science load of any cancer conference we attend each year. Sure there’s some nice clinical data, but that is like nibbling on the light appetizers before the 20 course banquet. You need much stamina and fortitude to survive the brain fog at AACR. Then there’s the glee at snagging some key poster handouts at the meeting, only to be rapidly diminished when you try to read the 4pt print post hoc and realise your eyes cannot focus easily.

Looking at the long list of topics I want to cover in the in-depth post meeting analysis for a ‘lighter’ post, especially given that it’s Friday after a very long week, that sinking feeling hit home hard – there are no lightweight topics at AACR.

The other day, we posted about the promising data in triple negative breast cancer (TNBC), following on from the Genentech and Merck presentations at the San Antonio Breast Cancer Symposium (SABCS). These data surprised many folks, mostly because they didn’t consider breast cancer to be an immunogenic tumour – nor is lung cancer in the broader scheme of things for that matter – yet we are seeing some nice durable responses in both tumour types with checkpoint inhibitors.

In other words, our definition and perceptions must change as we redefine how we identify and think of possible ‘responsive’ cancers to these agents.

So where are likely heading next?

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Quick Reminder: Today is the last day for the AACR Special – the discount ends at midnight ET tonight. We may not offer this rate again as it’s a limited time only deal!

As we’re coming to the end of our European Association Urology (EAU) coverage for 2015, I wanted to discuss at a rather more quirky, off-the-wall topic and look at one of the gems from the poster halls at this conference.

This year, it’s the turn of urothelial bladder cancer (UBC), a topic that doesn’t usually get much coverage or respect when it comes to new product development. Part of the challenge is the need for new targets to aim at because the particular patient population doesn’t tolerate high dose chemotherapy very well.

At ASCO last year, perhaps the surprise (and most stunning) data of the meeting was the anti-PDL1 checkpoint data (Genentech’s MPDL3280A) in refractory UBC, a disease where there are a lot of elderly and frail patients who are challenging to treat in many ways. This certainly put more attention on the disease and raised awareness to the potential opportunities for new, targeted and altogether more benign approaches to treatment. Subsequently at ESMO last fall, we also saw early data for an anti-PD1 antibody (Merck’s pembrolizumab) in advanced urothelial cancer.

Checkpoint blockade is not the only potential way to treat UBC though, so what other novel therapeutics are in development in this space?

To learn more about this evolving landscape, check out our quick review in the article below by signing up or logging in via the box below.

It’s now time to turn our attention to genitourinary oncology and, in particular, prostate, renal and urothelial bladder cancers. This week brings this ASCO GU meeting (#GU15), which is being held in Orlando this year and began this morning.

There are quite a few interesting topics being covered here, particularly in the poster sessions over the next three days. Hopefully, 2015 will also bring more good news in this space as 2014 was a rather dismal one on several fronts!

We decided to highlight some of the most interesting abstracts on castrate resistant prostate cancer and urothelial bladder cancer in our latest conference preview.

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Nature Cover Checkpoint InhibitorsIn a landmark publication today, the prestigious journal Nature includes five “Letters” regarding checkpoint blockade of the programmed death-1 (PD-1) receptor and its ligand PD-L1. It confirms the promise and potential of the emerging field of immuno-oncology to provide durable and long lasting responses in many cancers.

Readers of the blog will already have read about the stunning early data presented at ASCO this year for the engineered humanized antibody MPDL3280A (Genentech/Roche) in urothelial bladder cancer (UBC). In his Nature Letter, Thomas Powles (Barts) and colleagues sum of the significance of this data in the opening sentence:

“There have been no major advances for the treatment of metastatic urothelial bladder cancer (UBC) in the last 30 years.”

On the basis of this data, MPDL3280A received Breaththrough Therapy Designation from the FDA earlier this year.

Roy Herbst (Yale) and colleagues in their Nature Letter write about biomakers of PD-L1 inhibition and how their data “suggest that MPDL3280A is most effective in patients in which pre-existing immunity is suppressed by PD-L1, and is reinvigorated on antibody treatment.

At the recent annual meeting of the Society for Immunotherapy of Cancer (SITC), Dr Herbst gave one of the best presentations of the meeting, in which he discussed Personalized Immunotherapy for Non-Small Cell Lung Cancer.  His top ten lessons learned kept the audience’s attention throughout.

In this excerpt from an interview he kindly gave BSB afterwards, he talks about the promise of cancer immunotherapy in lung cancer:

 

Tomorrow is the Thanksgiving holiday in the United States, so this will be the only post this week. Thanksgiving is a good time to take a moment out of the hectic life we all live to “smell the roses” and express gratitude for all the positive things around us.

Next week sees the start of the American Society of Hematology (ASH) annual meeting in San Francisco. The cancer conference circuit seems to roll quickly from one meeting to the next at the moment. There’s a lot of promising data, and while we can’t discuss the data before the meeting due to ASH embargo restrictions, next week we will be highlighting some of the presentations we are particularly looking forward to.

Happy Thanksgiving!

Subscribers can login below or you can purchase access to read more detail about all five Nature Letters, and their implications for the emerging field of immuno-oncology.

Tower of London Field of Poppies

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