Original contributionFOXO1 down-regulation is associated with worse outcome in bladder cancer and adds significant prognostic information to p53 overexpression

•FOXO1 and p53 may have similar or synergistic effects in bladder cancer.•The combined study of FOXO1 and p53 expression may be a better prognostic indicator than p53 alone.•Having abnormal expression of any of the 2 genes is associated with disease progression in low-grade and pTa bladder urothelial carcinomas.•Having abnormal expression of both genes is associated with disease recurrence in high-grade and pT1 bladder urothelial carcinomas.

SummaryNuclear FOXOs mediate cell cycle arrest and promote apoptosis. FOXOs and p53 could have similar effects as tumor suppressor genes. In spite of extensive literature, little is known about the role of FOXO1 and its relationship with p53 status in bladder cancer. Expression of FOXO1 and p53 were analyzed by immunohistochemistry in 162 urothelial carcinomas (UC). Decreased FOXO1 expression, p53 overexpression and the combination FOXO1 down-regulation/p53 overexpression were strongly associated with high grade (P = .030; P = .017; P = .004, respectively), high stage (P = .0001; P < .0001; P < .0001, respectively) or both (P = .0004; P < .0001; P < .0001, respectively). In the overall series of cases, p53 overexpression was associated with tumor progression (hazard ratio [HR] = 3.18, 95% confidence interval [CI] 1.19-8.48, P = .02), but this association was even stronger if having any alteration in any of the 2 genes was considered (HR = 3.51, 95% CI 1.34-9.21, P = .01). Having both FOXO1 down-regulation and p53 overexpression was associated with disease recurrence (HR = 2.75, 95% CI 1.06-7.13, P = .03). In the analysis of the different subgroups, having any alteration in any of the 2 genes was associated with progression in low-grade (P = .005) and pTa (P = .006) tumors. Finally, the combined FOXO1 down-regulation/p53 overexpression was associated with disease recurrence specifically in high-grade (P = .04) and in pT1 stage tumors (P = .007). Adding FOXO1 expression to the immunohistochemical analysis of p53 can provide relevant prognostic information on progression and recurrence of bladder cancer. It may be particularly informative on the risk of progression in the more indolent and on the risk of recurrence in the more aggressive tumors.