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Immunotherapy for Bladder Cancer

What is Immunotherapy?

Immunotherapy is a type of cancer treatment that stimulates the body’s own defenses – the immune system – to fight cancer. The immune system is made up of white blood cells and organs and tissues of the lymph system that the body uses to fight infections and other diseases.

Immunotherapy can be used to:

kill bladder cancer cells
strengthen your immune system
stop bladder cancer cells from growing and spreading
lower the risk that the cancer will come back (recur)
help keep the cancer from coming back after it has already been treated (called maintenance therapy)
control symptoms of bladder cancer

What Immunotherapy Treatments are Used for Bladder Cancer?

There are two types of immunotherapies used to treat bladder cancer – cancer vaccines and immune checkpoint inhibitors.

Cancer Vaccines

Bacillus Calmette–Guérin (BCG) is a type of vaccine that is given intravesically (into the bladder via the urethra) to treat non-muscle invasive bladder cancer. It is a live bacterium that attracts immune cells, which then attack cancer cells. Since BCG is administered intravesically (placed directly into the bladder), the anticancer effects are local and side effects are primarily local as well.

To administer the BCG therapy, the doctor passes a tube (catheter) through the urethra and into the bladder. An immunotherapy drug is given through the tube into the bladder and is left in the bladder for 1 to 2 hours to give it time to work.

BCG Treatment Has Four Major Benefits:

This is a relatively non-invasive treatment process.
It can help you save your bladder and prevent the spread of cancer cells to other parts of your body.
It does not require any other medications to work effectively.
It stimulates the immune system to attack cancer cells without attacking healthy cells.

Immune Checkpoint Inhibitors

This type of immunotherapy works by stimulating the immune system, allowing immune cells to attack cancer cells. Immune checkpoint proteins sit on the surface of some types of immune cells, especially T cells, and some cancer cells. These proteins help keep immune responses in check and can keep T cells from killing cancer cells.

Cancer cells express such proteins to blunt the human immune system to react against the cancer. When these proteins are blocked with immune checkpoint inhibitors, the “brakes” on the immune system are released and T cells are able to kill cancer cells better. These drugs are given intravenously, typically every two to six weeks. This is an active area of research and many clinical trials related to immune checkpoint inhibitors are still ongoing. As a result, approvals for use of these drugs in Canada is also constantly evolving.

An immune checkpoint inhibitor may be offered as a second-line therapy for advanced or metastatic bladder cancer that:

is still growing during or after chemotherapy that includes cisplatin
comes back within 12 months of finishing chemotherapy

The immune checkpoint inhibitors used for bladder cancer target the PD-1 or PD-L1 checkpoint protein. They are:

Pembrolizumab (Keytruda) – most commonly used
Durvalumab (Imfinzi)
Atezolizumab (Tecentriq)
Avelumab (Bavencio) – may be used as a maintenance therapy after chemotherapy

Please discuss with your oncologist which immunotherapy drugs are currently available and which ones are recommended. Your healthcare team will consider your personal needs to plan the drugs, doses and schedules of immunotherapy.

Side Effects of Immunotherapy

Side Effects of Bacillus Calmette–Guérin (BCG) Therapy

With intravesical BCG therapy, the physician administers a liquid drug directly into your bladder, rather than orally or through injection into the bloodstream, which may lead to the following side effects:

a need to urinate (pee) more often than usual (frequent urination)
an intense need to urinate (urgent urination)
burning during urination
flu-like symptoms, such as fever, chills, fatigue and an achy body
loss of appetite

Side Effects of Immune Checkpoint Inhibitors

Unlike BCG, currently available immune checkpoint inhibitors are given systemically. Side effects of these drugs can include fatigue, loss of appetite, an allergic reaction, skin rashes and itchy skin. Since these medications work by removing the “brakes” on the body’s immune system, they can also cause inflammation of any normal tissue in the body (e.g. arthritis, colitis, pneumonitis). The immune system may start attacking other parts of the body, which can cause serious or even life-threatening problems in the lungs, intestines, liver, hormone-making glands or other organs.

Immune checkpoint inhibitors or monoclonal antibodies may cause these side effects:

fatigue
diarrhea
skin problems, such as a rash, dry skin and itching
nausea and vomiting
loss of appetite
low blood cell counts
lung problems, such as cough and difficulty breathing
inflammation of any organ (called an immune-related adverse event)
numbing of the hands and feet (peripheral neuropathy)
hair loss

It is very important to promptly report any new side effects to your health care team, both during and after treatment with immune checkpoint inhibitors. If serious side effects do occur, the immunotherapy may need to be held or stopped and you may be treated with corticosteroids (man-made drugs that closely resemble cortisol, a hormone that your adrenal glands produce naturally) to suppress your immune system.

Prompt recognition and treatment of these side effects is critical and may lessen the severity and duration of the side effects.

Immunotherapy may not be recommended for all patients, especially for those with pre-existing autoimmune conditions. Immunotherapy may also be used in combination with other treatments, such as surgery, radiation, or chemotherapy. Many new immunotherapies for bladder cancer are currently being investigated in clinical trials.

Navigating Bladder Cancer with Bladder Cancer Canada

Bladder Cancer Canada is the first and only patient advocacy organization in Canada dedicated to bladder cancer issues. Facing bladder cancer is undoubtedly a challenging journey, but with the support of the Bladder Cancer Canada community, you can find the strength and knowledge to navigate it more confidently.

Contact us for more information on Immunotherapy for Bladder Cancer.

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