CUA 2017: Update on Bladder Preservation in Muscle Invasive Disease

Toronto, Ontario (UroToday.com) Dr. Jason Efstathiou gave a talk on trimodal therapy (TMT) and bladder preservation in patients with muscle invasive bladder cancer (MIBC).

He elaborated on his 10 most important points of TMT:

1. Organ conservation is commonplace in contemporary oncology (but not yet in bladder). The urologist’s role in TMT is most important, mainly in the maximal TURBT in the beginning, in the cystoscopic re-biopsy for treatment response, surveillance, and when salvage radical cystectomy (RC) is needed.

2. Long term results of TMT are very good and comparable to RC, with improving complete response rates with time (86% in 2010-2013). This has been shown by both the Princess Margaret hospital experience1 and the Massachusetts general hospital experience.2 There is similar disease specific (DSS) in both TMT and RC ranging from 66% in 5 years to 59% in 10 years. Overall survival (OS) is also similar with 57% 5 year and 39% 10 year. There is significant disease upstaging at final pathology of RC of up to 40%.

3. Cystectomy is not being performed in 50% of patients in the USA– huge unmet need, TMT can fill this gap. National cancer database data has demonstrated that more than 30% of patients under 50 and almost 80% of patients over 80 do not undergo RC, although meeting necessary criteria. Increasing age is a significant factor withholding patients from undergoing RC. TMT is a potential solution for these aging patients.

4. Concurrent chemotherapy is important to the success of TMT. Several protocols of new trials are now being presented, comparing 5FU and cisplatin to Taxol and cisplatin, and 5FU and cisplatin to gemcitabine.

5. TURBT surgery and salvage RC are key to the success of TMT maximal complete TURBT.

6. Long term toxicity is acceptable and quality of life after bladder preservation is good (and probably better than in RC).

7. Superficial recurrences in TMT can be managed conservatively. Data has shown 25% of TMT patient developed non muscle invasive bladder tumors after complete TMT response. 60% of them were recurrence free after TURBT and BCG therapy. Importantly, they had similar tolerability, toxicity, and outcomes compared to non-radiated patients. 

8. The future is certainly promising with incorporation of stratification based on biomarkers.

9. Bladder preservation with TMT is supported by numerous guidelines, including the NCCN, EAU, and NICE.

10. Bladder preservation requires multidisciplinary teamwork, with consistent and effective collaboration between uro-oncologists, radiation oncologists, medical oncologists, and pathologists. 

Dr. Efstathiou concluded his presentation with some closing thoughts. In summary, many MIBC patients are not getting curative treatment (RC). TMT achieves complete response and preserves bladder in up to 85% of patients, while offering survival rates comparable to RC in selected patients. Long term quality of life in TMT is very good and the majority of relevant guidelines support this type of therapy. There is a need to validate predictive biomarkers and optimize concurrent and adjuvant therapies. Lastly, continued multidisciplinary engagement is a must, and we must allow patient directed informed decision making. 

Presented By: Jason Efstathiou, MD, Dphil, Massachusetts General Hospital, Boston, MA, 

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre   Twitter: @GoldbergHanan at the  72nd Canadian Urological Association Annual Meeting - June 24 - 27, 2017 - Toronto, Ontario, Canada

References: 
1. Kulkarni, G. S. et al. Propensity Score Analysis of Radical Cystectomy Versus Bladder-Sparing Trimodal Therapy in the Setting of a Multidisciplinary Bladder Cancer Clinic. J. Clin. Oncol. JCO.2016.69.2327 (2017). doi:10.1200/JCO.2016.69.2327

2. Giacalone, N. J. et al. Long-term Outcomes After Bladder-preserving Tri-modality Therapy for Patients with Muscle-invasive Bladder Cancer: An Updated Analysis of the Massachusetts General Hospital Experience. Eur. Urol. 71, 952–960 (2017).
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