|Year : 2017 | Volume
| Issue : 2 | Page : 104-105
Bladder cancer: 2017 and beyond
Ashish M Kamat
Department of Urology, The University of Texas MD Anderson Cancer Center, TX, USA
|Date of Submission||31-Aug-2016|
|Date of Acceptance||02-Sep-2016|
|Date of Web Publication||30-Mar-2017|
Ashish M Kamat
Department of Urology, The University of Texas MD Anderson Cancer Center, TX
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kamat AM. Bladder cancer: 2017 and beyond. Indian J Urol 2017;33:104-5
Among all the tumors of the urinary tract that fall under the purview of urologists, urothelial carcinoma is the one that is frighteningly common while still being deadly. Management of patients with nonmuscle-invasive cancer is complex enough with the nuances around Bacillus Calmette–Guerin therapy; the management of invasive disease is similarly complex and associated with high morbidity and mortality rates if not treated optimally. In this issue of the journal, we focus on the practical aspects of muscle-invasive bladder cancer, with an aim toward the implementation of advances in knowledge into real world practice.
It is imperative that patients with muscle-invasive disease have their pathology reviewed by expert pathologists if there is any doubt about the presence of variant histology (e.g., micropapillary, small cell, and plasmacytoid) since the management of these patients can vary significantly from that of conventional urothelial carcinoma. Challenges exist in recognizing and reporting these histologic variants in small transurethral resection (TUR) specimens, and collaborative efforts and centralized pathologic review (e.g., telere view) are steps which can be implemented even in remote areas of the country.
Appropriate staging workup includes cross-sectional imaging, including the chest, abdomen, and pelvis using contrast-enhanced computed tomography (CT) scan or magnetic resonance imaging; the value of positron emission tomography/CT in urothelial carcinoma is still evolving, even after a decade of study.
For muscle-invasive bladder cancer that is not metastatic, multimodal therapy involving radical cystectomy with neoadjuvant chemotherapy offers the best chance for cure. Radical cystectomy and pelvic lymph node dissection is well accepted as the gold standard but remains a complex surgery. Currently, much work (and debate) centers around ways to enhance patient recovery without affecting patients' cancer-related survival. Of the completed trials comparing the open to robotic approach for this surgery, some suggest no benefit from the robotic approach; larger studies are ongoing. Regardless of the technique used, surgeons' skill and volume is paramount. This is not a disease where the “learning curve” is forgiving of errors and a positive margin, for example, it is akin to a death sentence for many patients. As outlined by Smelser et al. in this issue, selected patients with muscle-invasive tumors can be offered bladder-sparing trimodality treatment consisting of maximal TUR followed by chemoradiation. This strategy has largely been ignored in many areas of the world and deserves to be resurrected. However, a large number of studies are needed, of which patients should initially be offered bladder preservation with chemoradiation approaches rather than surgery and the benefit of adding targeted and immunotherapeutic. Regardless of the definitive therapeutic option chosen, patient outcomes can be improved by attention to patient optimization, as outlined by Kukreja and Shah in this issue.
Advanced disease is best treated with systemic cisplatin-based chemotherapy; it is important to recognize that here, carboplatin has no role. Recent advances in checkpoint blockade immunotherapy are emerging as a viable salvage therapy for patients in whom first-line chemotherapy fails to control the disease. Atezolizumab is the first drug to be approved in the US for bladder cancer, after decades of stagnation.
What is truly exciting is the recent advances in molecular subtyping. Work performed by The Cancer Genome Atlas project and groups from MD Anderson Cancer Center, University of North California, Institut Curie, and Lund University, have shed light on genetic subtypes of bladder cancer that may differ from one another in responses to various treatments. It is well recognized that urothelial carcinoma of the bladder is not one disease but made up of many distinct subtypes that differ in their biology and response to chemotherapy and immunotherapy. Large intergroup studies have been designed to study whether gene expression patterns can reliably identify which patients are likely to respond to chemotherapy, molecularly targeted agents, or immunotherapy. Examples of such trials include the SWOG trial of the CO-eXpression ExtrapolatioN score to direct the choice of neoadjuvant chemotherapy for patients.
These are, indeed, exciting times for physicians and patients, both since after almost four decades of stagnation, the field is moving ahead with momentum building toward meaningful improvements in patient care and outcomes. It is not hyperbole to say that we are on the cusp of truly personalized and individualized management of patients with bladder cancer.
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