FOXM1 predicts disease progression in non-muscle invasive bladder cancer

J Cancer Res Clin Oncol. 2018 Sep;144(9):1701-1709. doi: 10.1007/s00432-018-2694-5. Epub 2018 Jun 29.


Purpose: The proto-oncogene forkhead box M1 (FOXM1) is associated with poor survival in many cancers. The impact of FOXM1 expression on progression-free survival (PFS) of non-muscle invasive bladder cancer (NMIBC) has not yet been investigated. The differential expression of FOXM1 between the different molecular NMIBC subtypes has further been assessed.

Methods: Transcript levels of FOXM1 and MKI67 were determined in 460 NMIBC patients (UROMOL cohort) by RNA-Seq and validated in silico by the Chungbuk and Lund cohort (n = 277). FOXM1 and MKI67 cutoffs were identified by the minimal p value method. Variables were evaluated by multivariable Cox regression analyses in order to identify independent predictors.

Results: FOXM1 is an independent predictor for PFS superior to current histological, clinical and molecular staging methods. Patients with high FOXM1 expression have a 6- to 8-fold higher risk of progression in multivariable analysis (p < 0.03). Highest transcript levels were found in the Class 2 and genomically unstable molecular NMIBC subtype (p < 0.03). The proto-oncogene further positively correlated with tumor grade and stage. NMIBCs with high FOXM1 expression showed a PFS advantage when treated with intravesical BCG instillation.

Conclusion: FOXM1 is a highly prognostic marker for disease progression of NMIBC superior to current histological, clinical and molecular staging methods and MKI67. It is mainly expressed in the Class 2 and genomically unstable molecular bladder cancer subtypes. Its role in drug resistance development makes FOXM1 valuable biomarker for NMIBC risk stratification.

Keywords: Biomarker; Bladder cancer; FOXM1; MKI67; Molecular subtypes; Progression-free survival.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Biomarkers, Tumor / genetics*
  • Disease Progression
  • Disease-Free Survival
  • Female
  • Forkhead Box Protein M1 / genetics*
  • Gene Expression Profiling
  • Humans
  • Ki-67 Antigen / genetics
  • Middle Aged
  • Neoplasm Recurrence, Local / genetics
  • Neoplasm Recurrence, Local / pathology
  • Neoplasm Staging / methods
  • Prognosis
  • Proto-Oncogene Mas
  • Urinary Bladder Neoplasms / genetics*
  • Urinary Bladder Neoplasms / pathology*
  • Young Adult


  • Biomarkers, Tumor
  • FOXM1 protein, human
  • Forkhead Box Protein M1
  • Ki-67 Antigen
  • MAS1 protein, human
  • Proto-Oncogene Mas