Bladder Preservation or Cystectomy for the Treatment of Muscle-Invasive Bladder Cancer, B-PRECISE Trial

Inclusion Criteria

• Patient must have signed written informed consent indicating understanding of the purpose of the study and willingness to participate prior to any protocol-related procedures, including screening evaluation
• Participants must have histologically confirmed cT2-cT4aN0M0 urothelial (transitional cell) carcinoma of the bladder. Mixed histology is acceptable as long as there is a majority component of urothelial carcinoma
• Availability of baseline archival tumor tissue obtained for molecular analysis and correlative studies
• Age ≥ 18 years
• Candidate for radical cystectomy
• Cisplatin eligible
• Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1
• Participants with evidence of chronic hepatitis B virus infection with an undetectable hepatitis B virus (HBV) viral load on suppressive therapy, if indicated, are eligible for this trial. Subjects with HBV infection, characterized by positive hepatitis B virus surface antigen (HBsAg) and/or anti-hepatitis B virus core antibody (HBcAb) with detectable HBV DNA (≥ 10 IU/ml or above the limit of detection per local laboratory standard), must be treated with antiviral therapy, per institutional practice. Following antiviral therapy initiation, subjects must show adequate viral suppression (ie, HBV DNA ≤ 2000 IU/mL) as prior to starting NAC. Participants will remain on antiviral therapy for the study duration and for at least 6 months after the last dose of systemic therapy. Subjects with HBV infection, characterised by positive HBsAg and/or anti-HBcAb with undetectable HBV DNA (< 10 IU/ml or under the limit of detection per local lab standard) do not require antiviral therapy prior to NAC. These subjects will be tested at every cycle to monitor HBV DNA levels; if HBV DNA is detected (≥ 10 IU/ml or above the limit of detection per local lab standard), antiviral therapy must be initiated, continued for the study duration and for at least 6 months after the last dose
• Participants with a history of hepatitis C virus (HCV) must have been treated and cured. For participants with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load
• Participants with a prior or concurrent history of malignancy whose natural history of treatment does not have the potential to interfere with the safety or efficacy assessment of the investigational protocol are eligible for this trial
• Leukocytes ≥ 3,000/mcL
• Hemoglobin ≥ 9.0 g/dL
• Absolute neutrophil count ≥ 1,500/mcL
• Platelets ≥ 100,000/mcL
• International normalized ratio ≤ 1.5 x institutional upper limit of normal (ULN) and activated partial thromboplastin time (aPTT) ≤ 1.5 x ULN * Unless the patient is receiving anticoagulation therapy provided international normalized ratio (INR) or partial thromboplastin time (PTT) is within the therapeutic range of the intended anticoagulant
• Total bilirubin ≤ institutional upper limit of normal (ULN) * This will not apply to patients with confirmed Gilbert’s syndrome (persistent or recurrent hyperbilirubinemia that is predominantly unconjugated in the absence of hemolysis or hepatic pathology), who will be allowed in consultation with their physician
• Aspartate aminotransferase (AST)(serum glutamic oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT)(serum glutamic pyruvic transaminase [SGPT]) ≤ 2.5 x institutional ULN
• Measured creatinine clearance ≥ 40 mL/min or calculated creatinine clearance 40mL/min by the Cockcroft-Gault formula (Cockcroft and Gault 1976) or by 24-hour urine collection for determination of creatinine clearance
• Evidence of post-menopausal status or negative urinary or serum pregnancy test for pre-menopausal female patients. Women will be considered post-menopausal if they have been amenorrheic for 12 months without an alternative medical cause * Women < 50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of exogenous hormonal treatments and if they have luteinizing hormone and follicle-stimulating hormone levels in the post-menopausal range for the institution or underwent surgical sterilization (bilateral oophorectomy or hysterectomy) * Women ≥ 50 years of age would be considered post-menopausal if they have been amenorrheic for 12 months or more following cessation of all exogenous hormonal treatments, had radiation-induced menopause with last menses > 1 year ago, had chemotherapy-induced menopause with last menses > 1 year ago, or underwent surgical sterilization (bilateral oophorectomy, bilateral salpingectomy or hysterectomy) * Women of child-bearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control; abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while she or her partner is participating in this study, she should inform her treating physician immediately. Non-sterilized men treated or enrolled on this protocol who are not abstinent and intend to be sexually active with a female partner of childbearing potential must also agree to use adequate contraception (male condom plus spermicide) prior to the study, for the duration of study participation, and 4 months after completion of treatment. Periodic abstinence, the rhythm method, and the withdrawal method are not acceptable methods of contraception. Male patients should refrain from sperm donation throughout this period. Even if the female partner is pregnant, male participants should still use a condom plus spermicide (where approved), as indicated above during the clinical study, if there is a concern about damaging the developing fetus from drug in ejaculate
• Patient is willing and able to comply with the protocol for the duration of the trial

Exclusion Criteria

• Patients with urothelial carcinoma of the ureter, urethra, or renal pelvis
• Contraindication for bladder radiation
• Inoperable primary tumor
• Any previous systemic chemotherapy or radiotherapy for bladder cancer or currently receiving systemic chemotherapy for another malignancy
• Inflammatory bowel disease
• Patients who are receiving or have received any other investigational agents within 6 months of study entry
• Child-Pugh class C hepatic impairment
• Known to have tested positive for human immunodeficiency virus (HIV) (positive HIV 1/2 antibodies) or active tuberculosis infection
• Receipt of the last dose of intravesical chemotherapy or biologic therapy ≤ 42 days (6 weeks) prior to the first dose of study drug for patients who have received prior intravesical chemotherapy or biologic therapy (e.g. Bacillus Calmette-Guerin [BCG])
• Uncontrolled intercurrent illness, including but not limited to, ongoing or active infection, symptomatic congestive heart failure, uncontrolled hypertension, unstable angina pectoris, unstable cardiac arrhythmia, symptomatic interstitial lung disease, serious chronic gastrointestinal conditions associated with diarrhea, or psychiatric illness/social situations that would limit compliance with study requirement, substantially increase risk of incurring adverse events (AEs) or compromise the ability of the patient to give written informed consent
• Judgment by the investigator that the patient is unsuitable to participate in the study and the patient is unlikely to comply with study procedures, restrictions, and requirements
• Pregnant women are excluded from this study because chemotherapy and radiation have the potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with chemotherapy, breastfeeding should be discontinued if the mother is treated with chemotherapy
• Patients with a history of allogeneic organ transplant, primary immunodeficiency, or active autoimmune disorder requiring immunosuppression should not receive immunotherapy but can be enrolled in the study with standard-of-care neoadjuvant treatment with chemotherapy
• Female patients who are pregnant or breastfeeding or male or female patients of reproductive potential who are not willing to employ effective birth control from screening to 90 days after the last dose of systemic therapy
• Known allergy or hypersensitivity to any of the study drugs or any of the study drug excipients