Current trends in the management of invasive bladder cancer

In muscle-invasive bladder cancer, attempts at cure have traditionally involved radical local treatment by either radiotherapy or ablative surgery. However, these treatments have been associated with a high morbidity and have failed to address the problem of subsequent metastatic disease, to which many patients eventually succumb (often within the first 3 years after treatment). Modern imaging techniques have led to much improved staging information, allowing careful selection of patients suitable for radical "curative" treatment; at the same time, patients identified as already having metastatic disease may be spared major surgery that is unlikely to influence the outcome of their disease. Reconstructive surgical techniques are beginning to transform the quality of life for patients offered radical surgery, by avoiding the need for traditional urinary diversion. In addition, the use of neo-adjuvant chemotherapy combined with radical local treatment addresses the problem of micrometastases at diagnosis and offers the prospect of improved survival, although the results of clinical trials are awaited to evaluate this further. Future advances in treatment may be expected to occur as our understanding of the biology of bladder cancer increases. Of particular value will be predictive information about the invasive potential of initially superficial tumours, so that these cases may be targeted for "aggressive" treatment from the outset.