Muscle-Invasive Bladder Cancer: The Evolving Treatment Landscape

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Patients diagnosed with MIBC are at a significant risk for death — which has not greatly improved in the last few decades.
Patients diagnosed with MIBC are at a significant risk for death — which has not greatly improved in the last few decades.

Each year, about 80,000 people are diagnosed with bladder cancer, and about 17,000 will die from the disease, which is the sixth most common type of cancer in the United States.1 Bladder cancer can be diagnosed as non-muscle invasive, muscle-invasive, or metastatic.

“Of patients diagnosed with bladder cancer, about 20% to 25% will be diagnosed with muscle-invasive disease,” said Peter C. Black, MD, of the University of British Columbia in Vancouver, Canada.

In the last year, patients diagnosed with metastatic disease have had several new immunotherapies added to their treatment options, including nivolumab, pembrolizumab, avelumab, durvalumab, and atezolizumab.2,3

In contrast, patients diagnosed with muscle-invasive bladder cancer (MIBC) are at a significant risk for death — which has not greatly improved in the last few decades.

Dr Black and other MIBC experts participated in an education session titled “Current and Future Directions of Muscle-Invasive Bladder Cancer” at the 2018 Genitourinary Cancers Symposium in San Francisco, in which they discussed how MIBC treatment is evolving.

Treatment Guidelines

According to Dr Black, one of the main challenges in MIBC treatment is that a lot of patients are likely undertreated.

“A lot of American database studies show that patients with MIBC are not getting preoperative chemotherapy, and are often not getting any curative intent treatment at all,” Dr Black said. “Part of the reason for this is it is an older population with a lot of comorbidities, so they are medically difficult to treat, and as a physician group we do not go a good job of following guidelines.”

In fact, the American Urological Association (AUA) and several other medical organizations only just published the first set of clinical guidelines for the treatment of non-metastatic MIBC in 2017.4

“In these guidelines, we outlined — based on published evidence — the best recommendations for the treatment of MIBC,” said Jeffrey M. Holzbeierlein, MD, of the University of Kansas Health System in Kansas City. During the education session, Dr Holzbeierlein discussed these guidelines and how they have changed the management of muscle-invasive disease.

According to the guidelines, cisplatin-based neoadjuvant chemotherapy should be offered to eligible cystectomy patients prior to surgery; radical cystectomy should be performed as soon as possible after the completion of and recovery from neoadjuvant treatment. Any patient ineligible for cisplatin-based neoadjuvant chemotherapy should proceed to definitive locoregional therapy.

Another important takeaway from the 2017 guidelines, according to Dr Holzbeierlein, is that clinicians must realize that not all patients are candidates for bladder removal — and patient preference is a critical factor.

“What we hope to do with targets and molecular markers is help to counsel patients,” he said. “We want to say, ‘Yes, you are a good candidate for bladder conservation techniques,' or ‘No, you are not, and if you choose that route you are choosing a therapy that is not likely to be successful.'”

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