87

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www.expert-reviews.com ISSN 1473-7140© 2012 Expert Reviews Ltd10.1586/ERA.11.195

Carmel Pezaro‡1,2, Mun Sem Liew‡1 and Ian D Davis*1,2,3

1Joint Ludwig Austin Oncology Unit, Austin Hospital LTB6, Heidelberg, VIC 3084, Australia 2Ludwig Institute for Cancer Research, Melbourne-Austin Branch, VIC 3084, Australia 3University of Melbourne, VIC 3010, Australia *Author for correspondence: Tel.: +61 394 96 5763 Fax: +61 394 57 6698 ian.davis@ludwig.edu.au

‡Contributed equally as first authors.

Urothelial carcinoma (transitional cell carcinoma) is the most common malignancy of the urinary tract. Urothelial carcinoma of the bladder is a common disease but has traditionally been underrepresented in both public awareness and cancer research. The purpose of this review is to provide an outline of the recent updates in understanding of urothelial cancer etiology, particularly with regards to lower tract muscle-invasive disease, and to discuss the identified mutations in high- and low-grade disease. We will consider evidence for the current systemic therapies for muscle-invasive and metastatic disease and review the targeted therapies under investigation for advanced urothelial cancer.

KEYWORDS:

Urothelial cancers: using biology to improve outcomesExpert Rev. Anticancer Ther. 12(1), 87–98 (2012)

EpidemiologyBladder cancer is a commonly diagnosed disease in Western society. In the USA in 2010 bladder cancer was expected to be the fourth most com-monly diagnosed cancer in males [1] and the inci-dence is projected to rise gradually over the next decade. Bladder cancer has been causally linked with tobacco smoking [2], occupational expo-sures [3] and treatment with cyclophosphamide chemotherapy [2]. Schistosoma hematobium infec-tion, found in endemic regions of Africa and the Middle East, is associated with the development of a squamous cell variant of bladder cancer [4]. Although no heritable genetic abnormalities have been identified yet, the possibility of low-penetrance genes or X-linked susceptibility has risen [5,6].

Pathology & pathogenesisThe vast majority of bladder cancers are epithe-lial in origin and of these, approximately 90% are transitional cell cancers, also called urothe-lial cancers [7]. The other, comparatively rare, epithelial and nonepithelial tumors will not be discussed in this review.

The pathogenesis of urothelial cancer remains controversial. It has been hypothesized that some solid tumors include rare populations of cancer stem cell-like cells [8]. These cells have reacquired the properties of stem cells, such as unlimited self renewal, asymmetric cell divi-sion and chemoresistance through enhanced drug efflux mechanisms [9]. There is little direct

evidence of this in urothelial cancer [10]. By con-trast, there is quite striking evidence to support a clonal origin for bladder cancer. Hierarchical cluster ana lysis of multiple tumors within indi-vidual patients supported a clonal relationship between the tumors, and suggested a sequential order of genetic aberrations that differed from the chronological order of tumor diagnosis and resection [11]. A monoclonal origin was also supported by comparative genomic hybridiza-tion on 32 tumors from six cystectomy speci-mens [12]. Finally, some studies support tumor development from independently transformed progenitor cells within ‘field effect’ bladder damage [13].

Classification of bladder tumorsThe most important prognostic factors in blad-der cancer are the tumor grade and an accurate description of tumor invasion. Bladder tumors are graded according to cytological appearance. The widely accepted WHO/International Society of Urologic Pathologists 2004 clas-sification system divides tumors into either low-grade or high-grade [14]. The most com-mon staging system for bladder cancer is the Tumor, Node, Metastasis (TNM) system [15], where the T stage depends on the depth of pen-etration through the anatomical layers of the bladder, assessed clinically (c) or pathologically (p). Ta tumors are outpouchings of low-grade malignant urothelium, which rarely progress to higher stage disease. Carcinoma in situ can

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be multifocal and carries a high chance of progression to inva-sive disease. T1 tumors extend into the lamina propria and are referred to as superficial or, more accurately, non-muscle invasive. T2 tumors are muscle invasive. Once deep muscle is involved, there is an approximately 30% incidence of lymph node metastasis, and this increases to approximately 90% if there is extravesical (T3) involvement [7]. T4 tumors invade adjacent structures such as the prostate, uterus, rectum or sigmoid, pelvis or abdominal wall.

Tumor spread can occur by local invasion, via lymph nodes, or hematogenously to distant sites [16]. Overall, approximately 11% of patients with noninvasive bladder cancer progress to more invasive cancer, although the 5-year risk varies from 1 to 45%, depending on risk factors including T score, tumor grade and presence of carcinoma in situ [17]. There is also a significant chance of recurrence of noninvasive bladder cancer, with 5-year recurrence rates of 31–78% depending on risk factors, of which the most prognostic are the number of tumors, tumor size and number/frequency of previous tumor resections [17].

Once bladder cancer has spread outside the bladder it is almost universally incurable, despite short-term responses to chemo-therapeutic agents. The recurrent nature of bladder cancer and the ease of tissue acquisition make it an ideal model for parallel tissue biomarker development during drug development and testing.

Molecular & cytogenetic changes in bladder cancerA number of somatic (acquired) mutations have been identified in urothelial cancer, including deletions within chromosome 9 [18] that occur in more than 50% of bladder tumors and that can lead to mutations in genes such as TSC1 [19]. There is increasing molecular and cytogenetic evidence that the pathogenesis of low-grade, non-invasive cancer is distinct from that in high-grade invasive disease. In noninvasive tumors, the predominant gene mutations are in FGFR3, which is mutated in approximately 70% of cases and is associated with favorable clinical outcome, and in PIK3CA [20]. These common mutations can be combined into a distinct molecu-lar profile for noninvasive, less aggressive disease [21]. By contrast, in high-grade disease TP53 mutations are present in more than half of cases, while mutations in the RB1 gene, nuclear accumulation of p21 protein, and hallmarks of invasion such as reduced E-cadherin, increased angiogenesis and increased breakdown of extracellular matrix are also seen [20,21]. Expression patterns of the TP63 gene, a member of the TP53 tumor suppressor family, have been associated with an aggressive phenotype in invasive tumors [22].

The understanding of the role of TP53 in urothelial cancer pathogenesis is still evolving. A meta-ana lysis published in 2005 concluded that there was not sufficient evidence to prove p53 as a marker of outcome in urothelial cancer [23], but this may change with more time. To add further complexity, expression of the p53 protein is not always concordant with gene status and appears independently associated with urothelial cancer stage and recurrence, allowing a three-tier stratification from best outcome in patients with a wild-type gene and normal pro-tein, to worst outcome in those with both mutated gene and altered protein expression [24]. A multicenter trial attempted to

assess whether patients with p53-positive tumors derived addi-tional benefit from adjuvant chemotherapy. Unfortunately, the study was halted early due to an interim ana lysis of futility and although ana lysis showed no difference in survival for patients with p53 positive pT1–T2 tumors, there was insufficient power to draw other conclusions [25].

Upper versus lower tract urothelial cancerUrothelial cancers of the pyelocaliceal cavity or ureter are classi-fied as upper tract urothelial cancers and make up 5–10% of all urothelial cancers [26]. There are additional recognized environ-mental risk factors for upper tract disease, including exposure to aromatic amines and certain plant-associated nephropathies [27] and also familial cases associated with the hereditary nonpolyposis colorectal cancer syndrome [28]. Upper tract tumors tend to be high grade and invasive at diagnosis [27]. Not only are concur-rent bladder tumors present in 8–13% of cases, but recurrence is also much more common in the bladder compared with the contralateral upper tract [27,29].

Identified genetic changes in upper tract tumors include over-expression of COX-2 [30] and expression of members 1, 3 and 4 of the claudin protein family, which play a key role in the formation of cell–cell junctions [31]. It is not yet clear whether changes in COX-2 or claudin expression are prognostic, although they appear to relate to grade and stage, respectively. Tumor methylation was found to be more common in upper tract tumors, with more extensive promoter hypermethylation [32]. Tumor methylation appeared to be associated with more advanced and aggressive disease. By contrast, FGFR3 mutations, which occur as com-monly as in lower tract disease, were associated with lower stage and more indolent disease [33].

Resistance mechanisms in urothelial cancerPlatinum drugs are the mainstay of systemic treatment for advanced urothelial cancer. These drugs bind DNA, causing cross-links and disrupting the cellular DNA structure [34]. In the setting of gene mutation causing deficiency of proteins, such as MMR or ERCC1, cells are able to continue to proliferate despite platinum-induced damage, resulting in platinum resistance [34]. In patients with urothelial cancer receiving cisplatin, low ERCC1 expression was associated with a longer median survival of 25.4 months, com-pared with 15.4 months for those with high ERCC1 expression [35]. High BRCA1 expression has been reported to predict poorer pathological response to neoadjuvant cisplatin [36]. There are also early reports that platinum response may be associated with certain patterns of germline single-nucleotide polymorphisms [37].

Clinical managementNonmuscle-invasive diseaseA total of 70% of bladder cancers are non-muscle invasive and these are treated with transurethral resection of bladder tumor (TURBT), usually followed by an adjuvant intravesical immuno-therapy such as bacillus Calmette–Guérin (BCG), which exerts an anti-tumor effect due to nonspecific immune activation; or chemotherapy, such as mitomycin C or anthracyclines. Adjuvant

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treatment has been shown to reduce the risk of recurrence and to delay progression to muscle-invasive disease but has failed to demonstrate a survival benefit [38,39]. A study using a 6-week adjuvant course of BCG therapy, with a minimum of 10 years of clinical follow-up, found a 10-year progression-free survival (PFS) rate of 61.9% compared with 37% for surgical resection alone [40]. However, a meta-ana lysis of 24 trials of BCG therapy, including 4863 patients, did not show a statistically significant difference in either death owing to bladder cancer or in overall survival (OS) [41]. The European Association of Urology recom-mends administration of single-dose intravesical chemotherapy within 24 h following TURBT for patients with superficial low- and intermediate-risk tumors [42], based on a 39% reduc-tion in risk of recurrent disease by meta-ana lysis following a single instillation of intravesical chemotherapy [39]. For patients at high risk of recurrence, immediate intravesical chemotherapy should be followed by maintenance intravesical BCG or further chemotherapy [42]. In patients at high risk of progression, con-sensus recommendation is for a 6-week induction course of BCG followed by maintenance BCG for up to a year [42].

Muscle-invasive diseaseDefinitive treatmentRadical cystectomy (RC) is a gold-standard therapy for muscle-invasive bladder cancer (MIBC). Stein et al. reviewed 1054 patients after RC and demonstrated 5-year disease-free survival (DFS) of 89, 60–78 and 50% in pT2, T3 and T4 disease, respectively [43]. Bladder-sparing approaches using chemoradiation have been suc-cessful in patients for whom cystectomy is not possible or not desired [44]. The evidence for bladder-sparing treatment is robust, and long-term data are available, showing that combined chemo-radiation can provide comparable response and survival rates with cystectomy [45]. Patient selection appears important, as the bladder- sparing approach works best in patients with an early stage, unifocal tumor, following complete transurethral resection [46].

LymphadenectomyThe role of radical pelvic lymphadenectomy at the time of cys-tectomy is somewhat controversial. No randomized study has been undertaken to prove a survival advantage, but database series, including a Surveillance, Epidemiology, and End Results review of almost 2000 cases, have shown a correlation between the number of lymph nodes examined and risk of death from bladder cancer [47], for both organ-confined and lymph node-positive dis-ease. Most treatment guidelines now include a recommendation for high- quality radical pelvic lymphadenectomy at the time of cystectomy [48].

As well as the presence and number of metastatic lymph nodes identified at lymphadenectomy, the presence of extracap-sular extension may provide prognostic information [49], how-ever, further assessment is needed. The largest reported series of 507 patients undergoing cystectomy and bilateral lymphadenec-tomy suggested extracapsular extension was present in 58% of cases and was an independent prognostic factor in multivariate ana lysis (p = 0.019) [50].

Neoadjuvant chemotherapyDespite substantial evidence, the practice of neoadjuvant chemo-therapy (NAC) prior to RC for MIBC remains inconsistent. Meta-analyses have demonstrated at least a 5% absolute survival benefit with NAC [51–54]. Despite this, an ana lysis of 7131 patients with cT3 MIBC showed that only 1.2% patients received NAC [55].

The advantages of NAC include the increased chances of kill-ing all cancer cells prior to surgery (pT0 resection) and improved resectability [56]. Pathological complete response (pCR), the stron-gest predictive marker for long term survival, can be achieved in 38 and 32% using combination methotrexate, vinblastine, doxorubicin and cisplatin (MVAC) and cisplatin, metho trexate and vinblastine (CMV) chemotherapy, respectively [52,57]. Administration of CMV before surgery resulted in an improve-ment of overall 10-year absolute survival by 6% in a Medical Research Council and European Organization for the Treatment and Cure of Cancer randomized trial [58]. Neoadjuvant tumor response parallels DFS and survival [52]. In addition, drug deliv-ery in preoperative patients is better tolerated because patients are fitter before surgery [56], whereas many patients experience postoperative complications and require significant delays before starting adjuvant chemotherapy [59].

Most clinical trials recruited patients with muscle invasive (cT2) disease based on TURBT specimen, but there is often dis-cordance between clinical and pathological staging. In a single-center series of 50 patients undergoing MVAC NAC there was a clinical staging error of 38% [60]. Current evidence suggests an increased survival benefit in higher-stage disease, with a relative survival benefit of 8% in pT2 disease compared with 17% in pT4 disease [54]. Patients with pT2 MIBC have excellent DFS with RC alone and current evidence suggests they could be spared unnecessary chemotherapy toxicity and surgical delay [61].

Most of the evidence supporting NAC used MVAC or CMV regimens. The doublet of gemcitabine and cisplatin (GC) has never been prospectively tested in the neoadjuvant setting but is often used, based on equivalence data extrapolated from the meta-static setting (see below). Three retrospective studies examined the benefit of neoadjuvant GC and showed pCR rates ranging from 7 to 26%, lower than that reported with MVAC (pCR 38%) [62–64]. While neoadjuvant GC seems a reasonable substitution in patients unable to tolerate MVAC, better evidence of equivalence in the neoadjuvant setting is required for patients who have no contraindication to MVAC. Carboplatin is occasionally substi-tuted in patients thought unfit for cisplatin, but the supporting data are suboptimal [65]. An alternative regimen of dose dense MVAC with granulocyte colony-stimulating factor support is used by some oncologists, but again this regimen has not been tested in the NAC setting.

One important concern is that patients who suffer serious tox-icity during NAC may not be well enough or may refuse RC. Herr evaluated the outcome of 63 patients who refused RC after complete clinical response following NAC [66]. Of these, 40 (64%) patients had recurrent disease and 23 patients (36%) subsequently died of disease, emphasizing the importance of RC as the definitive treatment.

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There are no published prospective comparisons between NAC and adjuvant chemotherapy in patients undergoing RC. A trial from the MD Anderson Cancer Center (TX, USA) tried to address this question by randomizing 140 patients with MIBC to either two cycles of NAC and three cycles adjuvant MVAC, or to five cycles of adjuvant MVAC following RC and pelvic lymph node dissection [56]. Although both groups had similar DFS at a median follow-up of 6.8 years, the NAC group had a lower rate of positive surgical margin (2 vs 11%) and a lower rate of pelvic lymph node metastasis (36 vs 22%) compared with those who had all their chemotherapy postoperatively.

Adjuvant chemotherapyThe major advantage of adjuvant treatment is that the treatment decision is based on pathologic staging on the cystectomy speci-men and, therefore, accurate identification of patients with pT3 and pT4 disease. Second, surgery is not delayed because of chemo-therapy toxicity or in nonchemotherapy responders. Despite these advantages, there are few randomized trials and the results are less convincing than NAC. Various regimens including MVAC, GC and CMV have been tested. However, these trials were often flawed owing to being underpowered, containing flaws in study design or were prematurely stopped because of poor accrual. A meta-ana lysis of six randomized controlled trials with a total of 491 patients showed a hazard ratio for death of 0.75, suggest-ing a 25% relative reduction in the risk of death [67]. However, this ana lysis was limited by the small size of individual trials and the nonadherence to intention-to-treat ana lysis. At present, many oncologists only consider adjuvant cisplatin based chemo-therapy for patients with perivesical tumor extension (!pT3) or node-positive disease [44].

First-line therapy for advanced or metastatic urothelial cancerAdvanced or metastatic urothelial carcinoma is a chemo sen-sitive disease. Various agents have shown single-agent activity in advanced urothelial cancer. However, responses to single-agent chemotherapy are generally of short duration and fail to provide improvement of OS and therefore combination regimens have been developed, primarily using cisplatin as a backbone (see TABLE 1 for summary data on combination chemotherapy trials).

The pivotal Phase III trial randomized 246 advanced or metastatic urothelial bladder cancer patients to receive either MVAC or single-agent cisplatin and demonstrated that com-bination chemotherapy improved overall response rate (RR: 39 vs 12%; p < 0.0001), OS (12.5 vs 8.2 months; p = 0.0002) [68] and PFS (6.6 vs 2.4 months) [69]. Following this trial, MVAC was regarded as the standard first-line regimen in advanced uro-thelial cancer. Updated survival with longer follow-up revealed that the absolute survival benefit from MVAC was 4.3%, and only 3.7% of patients were alive and disease free at 6 years [70]. Significant marrow and gastrointestinal toxicities were observed in the MVAC arm, with reported toxic death rates up to 4% [68]. In an effort to improve efficacy and decrease toxicity, a European Organisation for Research and Treatment of Cancer

Phase III trial randomized 263 patients to either standard MVAC or high-dose intensity MVAC regimen delivered every 2 weeks with growth factor support [71]. The primary end point of OS was not reached in the initial results but in the subsequent 7-year follow-up ana lysis there was little difference in median survival (15.1 months for high-dose MVAC vs 14.9 months for standard-dose MVAC), but a trend towards increased survival at 5 years (21.8 vs 13.5%; HR: 0.76) [72]. Dose-dense MVAC has not been widely used in Australia or other countries where granulocyte colony-stimulating factor support is not reimbursed for this indication.

Combination GC chemotherapy is considered an alternative standard first-line regimen on the basis of a Phase III trial that compared MVAC with GC in 405 metastatic urothelial cancer patients and demonstrated similar RR (49 vs 46%, respectively), PFS (7.4 months in both groups) and median survival (14.8 vs 13.8 months, respectively), with a toxicity profile that favored GC [73]. The OS and PFS remained similar in a subsequent 5-year follow-up ana lysis [74].

Recent therapeutic efforts have focused on improving efficacy by adding a third cytotoxic agent to GC. Paclitaxel combined with CG (PCG) was tested in a Phase III randomized trial that enrolled 627 patients to either CG or PCG chemotherapy [75]. PCG improved RR (57 vs 46%; p = 0.02) and CR (15 vs 10%; p = 0.02), but failed to demonstrate statistically significant improvement in OS (15.7 vs 12.8 months; p = 0.1). Not surpris-ingly, PCG treatment cause significantly higher rates of febrile neutropenia (13 vs 4%). In a Phase II sequential-treatment study, docetaxel was administered after standard GC [76]. This regimen resulted in an objective RR of 55.2%, a median time to progression of 6.8 months and an OS of 13 months. These data suggest the potential value of this strategy in advanced urothelial cancer.

A Phase II/III trial of gemcitabine, with or without vinflunine, as first-line treatment for patients ineligible for cisplatin has com-pleted accrual (ClinicalTrials.gov identifier: NCT00389155) and the results are awaited [201].

Second-line therapy for advanced urothelial cancerMost patients will progress after first-line treatment and require second-line treatment. Many chemotherapy and targeted ther-apy regimens have been investigated. Most agents showed either no activity in Phase II trials, or only demonstrated modest RR of 10–20%, median PFS of 2–3 months and median OS of 6–9 months [77]. At present there is no clear consensus regarding optimal second-line therapy.

The best studied second-line monotherapy is the vinca alkaloid vinflunine. Phase II testing suggested activity in adverse prognos-tic groups including patients with a short interval from prior plati-num therapy and visceral organ involvement [78]. The Phase III trial compared vinflunine to best supportive care in previously treated patients, the majority of whom had visceral metastases and a short disease-free interval after platinum therapy [79]. In the intention-to-treat ana lysis, the objective of a median 2 month survival gain was not statistically significant (6.9 vs 4.6 months;

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p = 0.287), but a multivariate ana lysis of eligible patients sug-gested an advantage for vinflunine. Grade 3/4 neutropenia was observed in 50% of patients receiving vinflunine, with febrile neutropenia in 6%.

Other cytotoxic agents have been studied as monotherapy in Phase I/II trials with disappointing efficacy and significant toxicity. Ifosfamide, an alkylating agent, was assessed in 56 eli-gible patients and showed an overall RR of 20% and PFS of 5.3 months, but there were four (7%) treatment related deaths [80]. Preliminary data suggest nab-paclitaxel (Abraxane®, Celgene, NJ, USA) may have useful second-line activity with an objective response in nine out of 29 (31%) evaluable patients [81]. In previ-ously treated platinum-based patients, monotherapy gemcitabine was evaluated in two separate Phase II trials. The 4-weekly sched-ule appeared to have higher objective RR (23%) [82] than the less dose-dense 3-weekly schedule (11%) [83]. Pemetrexed, a novel antifolate cytotoxic, showed significant clinical activity in the Phase II setting, with an overall RR of 28% and median PFS of 2.9 months in 47 evaluable patients with metastatic urothe-lial cancer and a tolerable toxicity profile [84]; however, a second

Phase II trial was closed after accruing 13 patients, due to lack of tumor activity [85].

Combination cytotoxic agents have shown better activity, but also increased toxicity. The most studied second-line combina-tion regimen is gemcitabine and paclitaxel (GP), which has been tested in various Phase II schedules and in a Phase III trial of 112 patients who were randomized between a standard six cycles of GP or maintenance GP until disease progression [86]. Both groups had similar OS (7.8 vs 8 months; p = 0.772) and PFS (4 vs 3.1 months; p = 0.488). In addition, more patients on maintenance GP experienced serious grade III/IV anemia, and there were two treatment-related deaths.

Targeted therapyThere is significant interest in using therapies targeting specific biologic pathways as first- or second-line treatments. These novel agents have different modes of action and generally have bet-ter toxicity profiles. A comprehensive understanding of urothe-lial tumor biology has highlighted several targetable molecular pathways in bladder carcinogenesis, including the EGF receptor

Table 1. Trials of first-line combination chemotherapy for advanced urothelial cancer.

Study (year)

Agents Patients (n)

RR (%) PFS (months)

OS (months)

Grade IV hematological toxicity (%) Ref.

Anemia Thrombocytopenia Neutropenia FN

Loehrer et al. (1992)

MVAC 126 39 6.6 12.5† 1.0‡ 6‡ 24‡ 10 [68]

Cisplatin 120 12 2.4 8.2 1.0‡ 2‡ 1‡ 0

Sternberg et al. (2006)

DD-MVAC 134 64 9.5 15.1† NR 11 8 10 [72]

MVAC 129 50 8.1 14.9 NR 6 16 26

Harker et al. (1985)

CMV 58 56 NR 8.0 NR 19 NR 24 [113]

von der Maase et al. (2008)

GC 203 49 7.4 13.8 3.5 29 30 2 [73]

MVAC 202 46 7.4 14.8 2 13 65 14

Dreicer et al. (2000)

CP 52 50 NR 10.6 0 0 52‡ 2 [114]

Bellmunt et al. (2007)

PCG 312 57 8.4 15.7 NR 7‡ NR 13 [75]

GC 315 46 7.7 12.8 NR 12‡ NR 4

Bamias et al. (2004)

CD + G-CSF

111 37 6.0 9.3 0 1 10 1 [115]

MVAC + G-CSF

109 54 9.4 14.2† 2 5 19 7

Boukovinas et al. (2006)

GC docetaxel

38 55 6.8 13.0 3‡ 11‡ 26‡ 0 [76]

†Statistically significant OS difference compared with comparator arm.‡Clinically significant either grade III or IV toxicity as reported in the study.

: Sequential treatment;CD: Cisplatin and docetaxel; CMV: Cisplatin, methotrexate and vinblastine; CP: Cisplatin and paclitaxel; DD: Dose dense; FN: Febrile neutropenia; GC: Cisplatin and gemcitabine; G-CSF: Granulocyte colony-stimulating factor; MVAC: Methotrexate, vinblastine, doxorubicin and cisplatin; NR: Not reported; OS: Overall survival; PCG: Paclitaxel, cisplatin and gemcitabine; PFS: Progression-free survival; RR: Response rate.

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(EGFR) and VEGF pathways. TABLE 2 summarizes efficacy and toxicity data for clinical trials utilizing targeted agents.

EGFR pathwayThe EGFR family consists of four receptors: Erb-B1 (EGFR/HER1), Erb-B2 (HER2/neu), Erb-B3 (HER3) and Erb-B4 (HER4). These receptors can transmit signals via RAS, MAPK pathway following ligand activation, regulating cell cycle progression that directly impacts on cancer progression.

GefitinibGefitinib is a small molecule inhibitor of EGFR. In urothelial cancer, gefitinib was tested in a second-line Phase II study, but showed minimal clinical activity [87]. Another Phase II trial combined gefitinib with cisplatin and gemcitabine as a first-line treatment. After amending the gemcitabine schedule because of excessive dose-limiting toxicity, final ana lysis showed a RR of 51% and median OS of 14.4 months, consistent with activity from GC alone [88]. A randomized Phase II trial of GC with or without concurrent or sequential gefitinib has been completed, and preliminary results are awaited (ClinicalTrials.gov identifier: NCT00246974) [201]. Another ongoing Phase II trial is evaluating consolidation therapy with docetaxel with or without gefitinib, following conventional first-line platinum based chemotherapy (ClinicalTrials.gov identifier: NCT00479089) [201].

ErlotinibErlotinib, an oral small molecule inhibitor of HER1 and HER2, has shown some growth inhibition and actin remodeling effects in urothelial cancer cell lines [89]. A Phase II trial of neo adjuvant erlotinib in 20 patients with muscle-invasive bladder cancer showed 25% pCR and 50% survival after a mean follow-up of 25 months [90]. There are very limited Phase II data of this EGFR inhibitor and its role in advanced urothelial cancer remains to be defined.

CetuximabCetuximab is a chimeric IgG1 monoclonal antibody specific for EGFR. Preclinical data in a xenograft urothelial model suggested that paclitaxel enhances the inhibitory effects of cetuximab [91]. This hypothesis is being tested in a Phase II trial investigating cetuximab with or without weekly paclitaxel as a second-line therapy (ClinicalTrials.gov identifier: NCT00350025) [201]. Another ongoing Phase II trial is assessing the efficacy of add-ing cetuximab to standard GC (ClinicalTrials.gov identifier: NCT00645593) [201].

Trastuzumab Trastuzumab is a humanized monoclonal antibody specific for HER2/neu/c-erbB2. Trastuzumab has well-established clini-cal activity in HER2 overexpressing solid tumors [92]. HER2

Table 2. Targeted therapies for urothelial cancer.

Regimen Design Patients (n) RR (%) PFS (months)

OS (months)

Ref.

EGFR pathway

Gefitinib PII, second-line advanced UC 31 PR: 3; SD: 6.5 2.0 3.0 [87]

Gefitinib + GC gefitinib

PII, second-line advanced UC 54 OR: 42 7.4 15.1 [88]

Erlotinib PII, neoadjuvant muscle-invasive UC

20 pCR: 25 NR 50.0 [90]

Trastuzumab + PCbG PII, first-line advanced UC 47 CR: 11; PR: 59 9.3 14.1 [96]

Lapatinib PII, second-line advanced UC 50 PR: 3; SD: 31 2.6 4.5 [98]

Antiangiogenic therapy

Bevacizumab + GC PII, first-line advanced UC 43 CR: 19; PR: 53 8.2 19.1 [101]

Aflibercept PII, second-line advanced UC 22 PR: 4.5 3.5 NR [102]

Multi-targeted TKI

Sunitinib (cohort A: 50 mg 4 weeks on, 2 weeks off; cohort B: 37.5 mg continuous)

PII, randomized, second-line advanced UC

Cohort A: 45Cohort B: 32

Cohort A: PR 7Cohort B: PR 3A + B: PR + SD: 43

2.4 vs 2.3(A vs B)

7.1 vs 6.0(A vs B)

[104]

Sorafenib PII, second-line advanced UC 22 SD: 14 2.2 6.8 [105]

Pazopanib PII, second-line advanced UC 30 PR: 13; SD:67 NR NR [108]

DV or placebo (DP) PII, randomized, second-line advanced UC

142 OR: 7 vs 11 (DV vs DP) 2.7 vs 1.7(DV vs DP)

6.3 vs 7.7(DV vs DP)

[109]

: Sequential treatment; CR: Complete response; DP: Docetaxel and placebo; DV: Docetaxel and vandetanib; EGFR: EGF receptor; GC: Gemcitabine and cisplatin; NR: Not reported; OS: Overall survival; PCbG: Paclitaxel, carboplatin and gemcitabine; pCR: Pathological complete response; PFS: Progression-free survival; PII: Phase II trial; PR: Partial response; RR: Response rate; SD: Stable disease; TKI: Tyrosine kinase inhibitor; UC: Urothelial cancer.

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overexpression in urothelial cancer correlates with poorer cancer survival and increased incidence of metastatic disease [93]. Using immunohistochemistry, 28–41% of urothelial tumors express HER2, with higher expression in high-grade tumors and in lymph node metastases [94,95]. Trastuzumab was combined with paclitaxel, carboplatin and gemcitabine in advanced urothelial cancer patients [96]. Of 109 enrolled patients, 52% had HER2 overexpression. Despite a grade 1–3 cardiac toxicity rate of 22.7% and two deaths from infectious complications, the study demon-strated a RR of 73% and median OS of 15.2 months. This prom-ising combination treatment warrants further Phase III testing, but dose modification may be needed. A European Phase II trial combined standard chemotherapy with or without trastuzumab in HER2-expressing advanced urothelial cancers patients and an interim safety ana lysis of 37 patients showed no difference in cardiac toxicity in both groups. This study failed to complete recruitment owing to low HER2 expression rate [97].

LapatinibLapatinib is a reversible noncovalent inhibitor of both EGFR and HER2 receptor tyrosine kinases. It has been investigated as a second-line therapy in a single-arm Phase II study [98]. Although this study failed to meet its primary end point of >10% objective RR, an unplanned subset ana lysis showed a significant survival benefit in patients with EGFR or HER2 over expression, compared with low HER2 expression (30.3 vs 10.6 weeks; p = 0.0001). These results highlighted the need for careful patient selection for targeted agent trials. An ongo-ing Phase II/III trial is assessing the role of maintenance lapa-tinib following first-line treatment in metastatic uro thelial cancer patients with HER1 and/or HER2 overexpression (ClinicalTrials.gov identifier: NCT00949455) [201].

Antiangiogenic therapiesAngiogenic signaling through the VEGF pathway is an important prognostic factor in many human cancers, including urothelial carcinoma [91]. The presence of VEGF has been correlated with tumor growth, metastasis and adverse outcome [99,100].

BevacizumabBevacizumab is a humanized IgG1 monoclonal antibody spe-cific for VEGF-A. A Phase II trial by the Hoosier Oncology Group assessed combination bevacizumab and GC as first-line therapy in 43 advanced urothelial cancer patients [101]. There was a promising 72% overall RR (19% CR; 53% PR), albeit with a considerable risk of venous thromboembolism (21%) and hemorrhage (7%). At a median follow-up of 27.2 months, the median PFS was 8.2 months and OS was 19.1 months. A Phase III trial of first-line GC with or without bevacizumab in urothelial cancer patients is currently recruiting patients (ClinicalTrials.gov identifier: NCT00942331) [201]. Other Phase II trials are assessing bevacizumab in combination with gemcitabine and carboplatin (ClinicalTrials.gov identifier: NCT00588666) [201] and neoadjuvant dose dense MVAC (ClinicalTrials.gov identifier: NCT00506155 [201]).

AfliberceptAflibercept, also known as VEGF-Trap, is a fusion protein com-prising high-affinity soluble VEGF receptor on an immuno-globulin backbone. It is a potent inhibitor of angiogenesis. A Phase II trial of 22 previously treated patients with metastatic urothelial cancer showed a modest clinical efficacy, including one partial response and median PFS of 2.8 months [102].

Multi-targeted tyrosine kinase inhibitorsSunitinibSunitinib, an oral small-molecule inhibitor of tyrosine kinases including VEGF receptor (VEGFR)-1, -2, -3 and PDGF receptor- and - , has shown in vitro activity both as a single agent and with cisplatin in urothelial carcinoma cell lines [103]. Gallagher et al. tested sunitinib in 77 patients who had failed at least one prior cyto-toxic treatment, with more than a third of patients treated with two or more prior treatments [104]. Two schedules were tested: cohort A included 45 patients treated with the standard schedule (50 mg daily 4 weeks on/2 weeks off), and cohort B included 32 patients treated with continuous 37.5 mg daily sunitinib. The overall clinical benefit (PR + SD) was 43%, with PR seen in four patients (three patients in cohort A and one patient in cohort B); the median PFS was 2.4 months and median survival was 6.9 months. There are Phase II trials assessing neoadjuvant sunitinib (ClinicalTrials.gov identifi-ers: NCT00859339 and NCT00847015) [201] and as a second-line treatment (ClinicalTrials.gov identifier: NCT00578526) [201].

SorafenibSorafenib is an oral small-molecule multikinase inhibitor that blocks cell proliferation via the ERK pathway and angiogenesis via the VEGF pathway. The clinical activity of sorafenib in uro-thelial cancer has been disappointing, with a Phase II study of second-line sorafenib in 22 advanced urothelial patients show-ing no clinical responses and a median OS of 6.8 months [105]. Similarly dismal responses were observed in the first-line setting [106]. Sorafenib has been studied in combination with first-line GC. The preliminary data suggested no additional toxicity, but efficacy data are awaited [107].

PazopanibPazopanib is an oral second-generation multi-targeted tyrosine kinase inhibitor targeting VEGFR-1, -2, -3, PDGF receptor and c-Kit. A Phase II study was conducted in heavily pretreated uro-thelial cancer patients [108]. Preliminary data was presented at ASCO 2011 (Chicago, IL, USA) demonstrating that a total of 63% of the 30 evaluable patients had a clear necrotic evolution tumor and decreased standardized uptake value on functional PET imaging.

VandetanibVandetanib is a novel, orally available tyrosine kinase inhibitor that selectively blocks VEGFR-2-dependent tumor angiogenesis and EGFR-dependent tumor cell proliferation. In a randomized Phase II trial of platinum refractory urothelial cancer patients, the addition of vandetanib to docetaxel failed to show improvement in RR, PFS or OS [109].

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Immunotherapy Anti-CTLA4 antibodyCytotoxic T lymphocyte associated antigen (CTLA-4) plays an important role in the regulation of the natural immune response. The presence of anti-CTLA-4 antibodies have been used to overcome the inhibitory B7-CTLA-4 signal, and this approach has shown good activity for the immunologic treat-ment of cancer [110]. Ipilimumab is a fully human monoclonal antibody that blocks CTLA-4 to promote anti-tumor immu-nity [111]. CTLA-4 blockade with ipilimumab has been tested in localized urothelial bladder cancer before radical cystectomy and four out of 12 patients showed a change from positive urine cytology and/or FISH ana lysis to negative urine cytology and/or FISH ana lysis [112].

Five-year viewThe management of non-muscle-invasive bladder cancer will probably remain stable over the next few years. To date, no agent has eclipsed the success of BCG therapy and the low rate of toxicity makes it an acceptable treatment for most patients. The accessibility of tissue, ease of biopsy and frequency of recurrence make this an ideal setting to study the effect of new therapies.

The most obvious advancement in the treatment of muscle-invasive bladder cancer would be to follow the current evidence and adopt a strategy of routine NAC for appropriate patients. Low rates of NAC often reflect inadequate education of urolo-gists and oncologists and poorly functioning multidisciplinary teams, but the success of neoadjuvant treatment in other tumor types should be strong motivation to create a smooth referral pathway with close communication between involved clini-cians. On the basis of current evidence, MVAC chemotherapy should be considered the regimen of choice in healthy patients, although GC is a reasonable alternative in patients who are unlikely to tolerate the toxicity of MVAC. A number of novel strategies, including targeted therapies, are being tested in the neoadjuvant setting and a less toxic option would certainly be welcomed.

Advanced urothelial cancer is undoubtedly a chemosensitive disease, but responses are often short-lived. The recent penchant for adding cytotoxic agents in ever-increasing combinations may add efficacy, but also adds significant toxicity to regimens. Sequential treatment strategies appear to hold some promise to

improve duration of response in a more tolerable manner, but these data are preliminary. Advances in cytotoxic therapies for urothelial cancer have been slow and it is unlikely that major practice-changing improvements on the basis of new regimens will be seen within the next 5 years.

Our understanding of resistance mechanisms is certainly increasing and it is to be hoped that this may someday translate to the ability to individualize treatment choices. Our ability to characterize urothelial cancer at a molecular level into aggressive and nonaggressive subtypes may also allow us to identify patients more likely to benefit from and respond to treatment.

There is a large number of targeted agents being tested in advanced urothelial cancer, which may lead to some significant advances in therapeutic options, including the possibility of combination or novel sequencing strategies in order to optimize responses based on better understanding of the biology of the cancer. The success of targeted agents will depend on intelli-gent trial design and innovative translational studies to identify patients most likely to benefit.

Expert commentaryAs for other genitourinary cancers, treatment of urothelial cancers may be at a crossroad. This is a chemosensitive cancer but significant work remains to be done in terms of develop-ing new and better cytotoxic regimens. Outcomes will almost certainly be improved if current evidence is applied more widely and more appropriately, particularly in terms of neoadjuvant and adjuvant therapy. Newly understood aspects of biology of urothelial cancer are suggesting novel treatment approaches, including better prediction of patients more likely to respond, selection of patients for targeted therapies based on charac-terization of key molecular events in the cancer, and systemic or local approaches integrated with novel therapies such as immunotherapy.

Financial & competing interests disclosureID Davis is supported by an Australian National Health and Medical Research Council Practitioner Fellowship. The authors have no other rele-vant 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 apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

There is a clear role for routine consideration of neoadjuvant and adjuvant chemotherapy in the treatment of muscle invasive urothelial cancer.To date, there has been slow uptake and adoption of evidence into practice.Many centers have moved beyond the evidence in routine clinical practice.Our understanding of the biology of urothelial cancer is improving.There is a requirement for development of better prognostic algorithms.Predictive biomarkers are required to be developed and tested in urothelial cancer.We must strive for the rational implementation of novel biologic and targeted therapies into clinical practice.

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