Selective organ preservation for the treatment of muscle-invasive transitional cell carcinoma of the bladder: a review of current and future perspectives

Abstract

Radical treatment remains underutilized for those with muscle-invasive bladder cancer. Radical radiotherapy, in particular, continues to be perceived by many as reserved only for patients unfit for cystectomy. However, with concurrent use of radiosensitizers, radiotherapy can achieve excellent local control and survival comparable to modern surgical series, thus presenting a real alternative to surgery. The possibility of further enhancing patient outcome is likely to come from both advances in radiotherapy treatment delivery and appropriate candidate selection. Growing evidence from selective bladder preservation trials demonstrate long term survival with functional organ preservation. In the era of personalized medicine, we review the evidence supporting an individualized treatment approach, in particular case selection for radical radiotherapy.

Keywords::

• biomarkers
• bladder cancer
• chemotherapy
• cystectomy
• radiotherapy
• selective bladder preservation
• tri-modality treatment

Acknowledgements

The authors acknowledge NHS funding to the NIHR Biomedical Research Centre for Cancer and to Cancer Research UK (CRUK).

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The prognosis for bladder cancer patients remains poor and has not improved significantly over recent years.

• There is level I evidence supporting the use of platinum-based neo-adjuvant chemotherapy in improving overall survival, but it is not widely used.

• Retaining native bladder function while maximizing cancer cure is an important aspect of treating patients with localized muscle-invasive bladder cancer.

• Organ preservation using tri-modality treatment including TURBT, chemotherapy and radiotherapy is safe and does not compromise survival; surgery can be reserved for non-responders and local relapse following radiotherapy without compromise to survival.

• Appropriate patient selection is necessary to determine the treatment approach most likely to benefit the individual. Biomarkers will further inform patient selection and treatment approach.

• Further gains in bladder preservation will be made by improving radiotherapy delivery techniques and with the use of individualized cytotoxic and biological agents.

Notes