Giving immune-system-boosting drugs to cancer patients before surgery rather than afterwards significantly decreases the chances of the disease returning, research suggests.
In a pivotal trial, bladder-cancer patients were given the treatment, known as immunotherapy, for two months in the run-up to having their diseased bladder removed, and some arrived for the procedure completely cancer-free.
At present, most bladder-cancer patients have their bladder removed, with many then receiving immunotherapy for a year to give them the best chance of a cure.
In a pivotal trial, bladder-cancer patients were given the treatment, known as immunotherapy, for two months in the run-up to having their diseased bladder removed, and some arrived for the procedure completely cancer-free
At present, most bladder-cancer patients have their bladder removed, with many then receiving immunotherapy for a year to give them the best chance of a cure
While all patients on the new trial still had their bladders removed as a precaution, researchers believe the extraordinary early findings – the trial is still ongoing – could revolutionise cancer care and allow some patients to escape the life-changing surgery.
‘We were genuinely stunned when we saw the results,’ says Professor Thomas Powles, director of the Barts Cancer Centre in London and lead researcher for the trial.
‘We never expected to see so many patients cancer-free after just two months of treatment. This is really significant.’
The final results of the study are due to be published in February. Should they be equally positive, it will join the ranks of a growing number of clinical trials that show that immunotherapy drugs are far more effective when given before surgery.
One study, published last month, found that giving two immunotherapy drugs to patients with colon cancer before surgery produced an ‘unprecedented’ response.
After 13 months, not a single patient had seen their disease return – when it would be expected that at least one in 20 on standard treatment regimes would suffer a relapse.
Another recent study found that patients who were given immunotherapy for three months before surgery to remove cancerous moles were significantly less likely to see the disease return.
‘For many years, the conventional wisdom has been that the best time to give immunotherapy is after surgery,’ says Prof Powles. ‘But the evidence increasingly suggests that giving the drugs beforehand has far better outcomes.
‘In the not-too-distant future, we could decide before a patient is due to have surgery whether they will actually need the procedure based on whether we can spot any cancer cells in their blood.’
Every year, more than 10,000 Britons are diagnosed with bladder cancer. If the disease spreads to other organs, as is often the case, it becomes almost incurable – and each year more than 5,000 Britons die from it.
In an effort to prevent this happening, many patients undergo radical surgery to remove the bladder and surrounding organs, such as the prostate in men and the uterus in women.
Patients whose cancer is considered at high risk of returning are given medication for 12 months in an effort to eliminate any remaining traces of the disease. In the past, these patients were given chemotherapy.
But as of last year, Britons with high-risk bladder cancer – just under 1,000 every year – are now given immunotherapy.
These drugs train the immune system to seek out and destroy cancer cells. It is more effective than chemotherapy in many types of cancer, and often causes fewer side effects.
‘Immunotherapy is a much more targeted approach, and far more beneficial for patients,’ says consultant urologist Dr Bernadett Szabados, a senior clinical researcher at Barts Cancer Centre.
But immunotherapy is not without risks. Roughly one in ten patients will experience painful liver inflammation. Even those with milder side effects experience symptoms such as diarrhoea and skin rashes. In many cases the cancer returns – and often it is more resistant to medications.
‘Bladder cancer returns in about 60 per cent of cases,’ says Dr Szabados. ‘And when it has come back, it has spread to other organs and become incurable.’
Since July 2021, researchers at Barts Cancer Centre have been investigating whether giving immunotherapy before bladder surgery could reduce the risk of the disease recurring.
‘We know that immunotherapy works best when there is visible cancer to attack,’ says Prof Powles. ‘So the thinking was that if there is a larger amount of tumour present, the drugs would be better at recognising it and destroying it.’
The trial recruited 25 bladder-cancer patients who were given two rounds of an immunotherapy drug called atezolizumab.
Then, before surgery to remove their bladder, they underwent scans, and it was found that in 50 per cent of patients the cancer had disappeared.
‘One patient was a man in his mid-50s with a golfball-size tumour in his bladder,’ says Prof Powles. ‘The cancer was deep in the muscle lining. We’d already tried to scrape it out but it wouldn’t budge. So we put him on the atezolizumab trial.
‘The treatment wasn’t without side effects – he had some nausea and fatigue – but when he showed up for a CT scan nine weeks after the first dose, we couldn’t find the cancer anywhere and neither could the surgeons when they went in to take out the bladder. Six months later, the cancer still hasn’t returned.’
Doctors are hopeful that in the coming years, the NHS will approve the use of immunotherapy earlier on in the treatment of cancer.
They argue that doing so would reduce the number of patients later requiring life-saving treatment and, in doing so, reduce the burden on services.
‘This new approach will almost certainly prevent disease recurrences in the future,’ says Dr Szabados. ‘And it could cut the number of patients who require life-changing surgeries in the future. People could keep their bladder.’
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