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GU Cancers 2023 | Does every patient with localized muscle-invasive bladder cancer need a cystectomy?

Siamak Daneshmand, MD, University of Southern California, Los Angeles, CA, discusses whether every patient with localized bladder cancer, especially muscle-invasive bladder cancer (MIBC), require a cystectomy. Patients may be too frail to undergo a cystectomy, and for many patients there may be more tolerable treatment options such as trimodal therapy (TMT). TMT consists of transurethral resection, radiation therapy, and radio-sensitizing chemotherapy and is currently under investigation in combination with immunotherapy in the Phase III SWOG1806 (NCT03775265) trial. Other bladder-preserving options are assessing intravesical delivery options of treatment with PD-1/PD-L1 inhibitors in combination therapy for disease control and longer disease-free survival (DFS). This interview took place at the ASCO GU Cancers Symposium 2023 in San Francisco, CA.

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Transcript (edited for clarity)

Well, the answer to that maybe 10 years ago would’ve been yes. But we are seeing a lot more options for patients. The reality is that many patients with muscle invasive bladder cancer actually don’t end up getting any treatment because we think they’re, either we or the referring physicians within the community think they’re too frail for a cystectomy and end up not really getting any therapeutic or curative type treatment...

Well, the answer to that maybe 10 years ago would’ve been yes. But we are seeing a lot more options for patients. The reality is that many patients with muscle invasive bladder cancer actually don’t end up getting any treatment because we think they’re, either we or the referring physicians within the community think they’re too frail for a cystectomy and end up not really getting any therapeutic or curative type treatment. So there is a large population of patients out there that we’re not even seeing to assess for surgery. So the answer is no, not everybody needs a cystectomy. In fact, most patients perhaps may not make it to cystectomy either because there are alternatives that are more palatable for them or they’re just really not a candidate for this surgery. So there are a number of things that we’re seeing.

So one is chemoradiation has always been around this idea of trimodality therapy or TMT where we do a good resection. Then the patients are treated with chemotherapy and radiation therapy, highly effective treatments. So that’s sort of coming up as a more palatable option for patients. There are a lot more studies now looking at long-term results comparison with surgical series that show really quite efficacious. So there’s renewed interest. Again, it’s been around for a long time, but there’s renewed interest and buy-in, I think from urologists to explore TMT a little bit further and further other combinations of treatments including immunotherapy. So there are a number of trials such as the SWOG1806 study right now looking at TMT +/- immunotherapy to see whether we can improve on those results for those patients. So those are exciting results that we’ll see in the future.

There are other bladder preserving options as well where we’re seeing a novel intravesical delivery options of medications along with PD1 or PD-L1 inhibitors in combination therapy to try to control the disease. And potentially even have a long recurrence free survival or long disease free survival for these patients who traditionally would’ve gone to cystectomy.

So we’re very excited that we have other options available for patients. There’s lots of clinical trial activity within this space that is new and for us who’ve been in this space for a long time. And really there’s been such a paucity of trials we’re, we’re very excited to have these options available for patients to offer other non-cystectomy options to them.

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