Prognostic factors and therapy for superficial and invasive bladder cancer

Although most of the transitional cell carcinomas are superficial at presentation and pose little problem as far as survival is concerned, predicting the ones that will recur and, more importantly, recur as invasive tumors, is crucial. Determination of serum and urine human chorionic gonadotropin-beta levels and epidermal growth factor receptor analysis are promising in this respect. Intravesical bacillus Calmette-Guérin, which is widely used to prevent further recurrences and to treat carcinoma in situ, augments the host's immune status, probably by increasing interleukin-2 and tumor necrosis factor levels. Intravesical interferon seems to be a promising agent, especially against carcinoma in situ, and has exceptionally few side effects. Multidrug chemotherapy regimens such as methotrexate, vinblastine, doxorubicin, and cisplatin, or cisplatin, methotrexate, and vinblastine have achieved 30% to 40% objective complete remission rates in patients with metastatic bladder cancer. These regimens are also used in a neoadjuvant setting with or without irradiation in the hope that more patients will be spared cystectomy and enjoy similar if not better survival. At the same time, continent diversions and nerve-sparing cystoprostatectomy open a new era in the treatment of invasive bladder cancer by improving the quality of life after cystectomy. Although important progress has been made, there is still room for research and clinical controlled studies to achieve higher rates of response, prolonged disease-free survival, and perhaps even improved rates of cure.