Current Landscape and Future Directions on Bladder Sparing Approaches to Muscle-Invasive Bladder Cancer
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Genitourinary Cancers (S Gupta, Section Editor)
Current Landscape and Future Directions on Bladder Sparing Approaches to Muscle-Invasive Bladder Cancer James R. Broughman, MD Winston Vuong, MD Omar Y. Mian, MD, PhD* Address * Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Avenue, CA-50, Cleveland, OH, 44195, USA Email: [email protected]
* Springer Science+Business Media, LLC, part of Springer Nature 2020
This article is part of the Topical Collection on Genitourinary Cancers Keywords Bladder cancer I Radiation therapy I Bladder preservation I Urothelial Cancer
Opinion statement Although radical cystectomy is considered the gold standard approach for patients with muscle-invasive bladder cancer, tri-modal therapy (TMT) is a well-tolerated and efficacious alternative to radical cystectomy that is underutilized in inoperable patients and rarely offered to cystectomy candidates in the USA. Retrospective data suggest similar outcomes between radical cystectomy and TMT after adjusting for patient selection and other confounding factors. Nearly 70–80% of patients can keep their native bladder with favorable post-treatment quality of life metrics. Current trials are investigating novel combination strategies including immune checkpoint inhibition along with chemoradiation or radiation. Emerging techniques for improved patient selection and risk stratification include incorporating MP-MRI, and novel biomarkers such as inflammatory, stromal, and DNA damage response gene signatures may guide patient selection and expand the landscape of bladder preservation options available to patients in the future.
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Curr. Treat. Options in Oncol.
(2021) 22:3
Introduction Bladder cancer is the most common malignancy of the urinary system with over 80,000 cases and nearly 18,000 deaths estimated in the USA in 2020 [1]. The majority of patients present with early stage, nonmuscle-invasive disease which may be managed with a transurethral resection of bladder tumor (TURBT) and intra-vesical therapy. Muscle-invasive bladder cancer (MIBC) is defined as T2 or greater disease and represents 25% of cases. The most common treatment for MIBC is neoadjuvant chemotherapy followed by radical cystectomy, which involves removal of the bladder and prostate for men and anterior exenteration (including the bladder, uterus, ovaries, and part of the vagina) for women. However, radical cystectomy is associated with significant morbidity and impact on quality of life particularly with increasing age. In a population-based study, the 90-day mortality rate following cystectomy was 5.4% for patients 70–79 years old and 9.2% for patients greater than 80 years old [2]. Because bladder cancer is predominantly a disease of the elderly with a median age of 70 at time of diagnosis, many patients are unfit for surgical management due to age-related functional decline or co-morbidities. Smoking is a primary risk factor for bladder cancer, and patients commonly have smoking-related co-morbidities such as chronic
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