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Immuno-oncology is the present and the future of the cancer approach.

This treatment approach has been able to respond to rare diseases that did not have specific therapies a few years ago, even improving the prognosis of the disease and the quality of life, but not only that, it also proving to be able to extend the life of the persons.

Specifically, one of the advances that is being achieved, thanks to constant research, is to increase the survival of patients with bladder cancer, a tumor in which there has been no significant progress for 30 years.

Sometimes tumors develop mechanisms to defend themselves and hide from the body's immunosurveillance system, producing a phenomenon called tumor escape.

Although for decades there have been first-generation treatments that aim to stimulate this system,

the advances that have been made in the last five years

in the development of immunotherapy treatments have meant a

radical change in oncology


When a tumor develops, it is recognized by cells (dendritic cells) whose function is to identify, capture and process the information, to take it to the nearest lymph node.

In the lymph node, the dendritic cells present information to the lymphocytes so that they develop a response of cells and antibodies directed specifically against the tumor.

This is a complex process in which there are several checkpoints that modulate the intensity of the immune response as needed.

To distinguish tumor cells from normal cells, the immune system induces the expression of proteins such as PDL1 in non-tumor cells, which once recognized by the PD-1 protein of lymphocytes prevent the attack on them, directing it directly against the tumor.


sometimes the tumor is capable of also synthesizing this PDL1 molecule as a mechanism of "tumor escape to the immune system


The new anti PD1 and PDL1 drugs counteract this tumor escape mechanism and reactivate the effective immune response against the tumor.

"This is the basis of most of the therapeutic advances that have occurred in immuno-oncology, in the last five years in many tumors, and especially important within genitourinary tumors. In kidney cancer and especially in bladder cancer ", explains

Jose Ángel Arranz, president of the Spanish Genitourinary Oncology Group

(SOGUG) and oncologist at the Gregorio Marañón Hospital, adding that" these drugs have shown a significant increase in the survival of patients in different cancer scenarios. renal and urinary bladder ".

Bladder cancer is a disease closely related to smoking, in Spain there are around 20,000 new cases a year, being the fourth most frequent tumor in men (with 80% of the total).

Each year, nationwide,

between 4,400 and 5,000 people die from this type of cancer, for which three different scenarios are known

: superficial localized tumors, localized tumors that have invaded the muscle layer, and metastatic disease.

The traditional treatment is transurethral resection of the tumor or even a radical cystectomy (removing the bladder), through surgery.

To this is added a treatment with perioperative chemotherapy that can be administered before or after the operation.

At present, clinical trials are being carried out in this situation with anti-PD-L1 or anti-PD-1 drugs, as a treatment after removing the bladder, and in fact we already know that these drugs offer an additional benefit here by prolonging the time to disease progression, and may even be avoided in some patients, "says Arranz.

However, according to the oncologist, the greatest advances are being observed so far in patients with metastasis, regardless of whether it appears after surgical resection or is diagnosed at the beginning.

"There are already at least

six ongoing studies that are testing the efficacy of adding anti-PD-L1 or anti-PD-1 drugs to chemotherapy

. In fact, immunotherapy has recently been shown to provide promising results, increasing survival overall of patients ".

Rare diseases

Immunotherapy treatment research is advancing rapidly in cancer types with higher incidence, such as bladder, breast or lung cancer.

The reason is that there are more patients for clinical trials, however, in the rare disease landscape progress is slower, but just as hopeful.

"Patients with many of these rare diseases, such as Merkel cell carcinoma, a type of skin cancer more aggressive than melanoma, had no more treatments once they were out of surgical control. They were very inactive chemotherapies that were also they supplied an already fragile population group such as the elderly, immunosuppressed and transplanted people.

Surgery used to be used because we had no other options

, but thanks to immunotherapy we are evaluating whether this type of surgery is really necessary " says Pilar López, an oncologist at the MD Anderson Cancer Center Hospital in Madrid.

The doctor emphasizes that these new treatments do not replace a good initial diagnosis and an early approach, that is, "if there is a patient with Merkel cell carcinoma, surgery and marking and even sentinel nodes must be done. In advanced stages , the new drugs provide a benefit that was unknown to date, but they are not yet effective in 100% of the patients, "says López.

Prevention in the case of this disease, with an incidence of one or two cases per million, is not easy.

It is not a tumor associated with sun damage such as melanoma

, in fact, it is more related to a virus that receives the same name as the disease.

There are Merkel tumors that, if found in early stages, require less aggressive surgeries.

But there are other cases, with more advanced tumors or metastatic patients, in which immunotherapy makes a difference.

"Five years ago, when we saw patients with metastases, we faced a very complicated situation because we had nothing to treat them with. Now, thanks to immunotherapy, we already have results of 70% of clear benefit in patients. We have gone from treatments with great toxicities, such as chemotherapy, to much less toxic and more active drugs ", emphasizes the oncologist.

Pilar López explains that when faced with a patient in relapse or who is directly diagnosed with metastasis, first-line treatments are immunotherapy, since they work much better in terms of efficacy and toxicity.

Both experts highlight

the importance of clinical trials in advancing immunotherapy treatments


"Spain is a privileged country from the point of view of patient participation. In all clinical trials that have shown survival benefits or tumor progression times, there has been broad Spanish participation, in many cases the country being that more patients have incorporated into these studies, "explains Arranz.

The oncologist also emphasizes that the patient is never under-treated in a clinical trial, the usual thing is to offer him the treatment that would correspond to him in a normal situation together with the treatment under investigation.

"For ethical and scientific reasons the patient never loses," concludes Arranz.


With the collaboration of the Merck-Pfizer Alliance

According to the criteria of The Trust Project

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