GU Cancers 2019 | Determining the optimal local treatment for muscle-invasive bladder cancer

So muscle-invasive bladder cancers are a vexing problem we have for urothelial cancer because, although they present only about a quarter of the time – so about 25% percent of patients who present will have muscle-invasive bladder cancer, they have a lot of potential to unfortunately progress or metastasize. So, the key treatment option that we’ve offered patients for the longest time is radical cystectomy. For men, that includes radical cystoprostatectomy with lymph node dissection. And especially neoadjuvant chemotherapy. And for women, we often add interior pelvic dissection.

So, the true standard of care I think is currently evolving. A lot of the guidelines have initially set out that surgery should be the treatment option for muscle-invasive bladder cancer with the addition of neoadjuvant chemotherapy. But there has been a lot of interest right now with using trimodality therapy. So trimodality therapy means we perform maximal TURBT. So that’s transurethral resection of the bladder tumor, followed by chemoradiation. So right now what often happens in practice is that patients who are otherwise fit for surgery usually goes for surgery. And those who are unfit for surgery usually are committed to chemoradiation.

But a lot of times, we are seeing that trimodality therapy is really emerging as an important and viable alternative for patients who want to keep their bladder. So certainly a lot of the treatment options for trimodality therapy includes fine-tuning and really selecting the right patient population.

So I think it is very important to have that in-depth discussion with patients. A lot of times, there are other things that we look at. How much tumor is there? Is it one tumor versus multiple tumors? Is there presence of hydronephrosis? Are these patients cisplaitin-eligible or not? Because those are the things that would shape the discussion and the decision for treatment. A lot of times, if patients are able to receive neoadjuvant chemotherapy followed by surgery, certainly that is a discussion that we put forth for patients.

Unfortunately, not everybody is going to be a surgical candidate. And therefore trimodality therapy is emerging as a probable, viable, as well as maybe an alternative option for these patients. So it is very important that we achieve maximal TUR, meaning we are able to resect all the visible tumors before they undergo chemoradiation. So I think it is a shared patient decision making that we conduct with our patients.