Are we undertreating invasive bladder cancer? Optimizing outcomes in a high-risk disease

To highlight the important issues that may improve patient outcomes in the setting of invasive bladder cancer.

Although approximately 80% of patients with bladder cancer present with disease confined to the mucosa which can be treated locally, progression to muscle-invasive bladder carcinoma (MIBC) is associated with adverse outcomes. Stage and grade have traditionally been used to predict progression. European Organization for Research and Treatment of Cancer (EORTC) and Club Urológico Español de Tratamiento Oncológico (CUETO) have designed prognostic models that further refine risk assessment. Recent attempts to integrate molecular biomarkers may further improve these models. Treating appropriate patients earlier with radical cystectomy offers the hope of decreasing the extent of disease at the time of surgery. In patients with MIBC, neoadjuvant chemotherapy has been shown to improve patient outcome. Selecting appropriate patients remains a challenge. Preoperative models to predict risk of lymph node-positive disease and preoperative imaging with fluorodeoxyglucose positron emission tomography or MRI have been shown to be useful in that regard. Multidisciplinary care offers better patient support and collaboration during the treatment phase and improves quality of life.

Improved outcomes in localized bladder cancer requires an integrated approach including better identification of high-risk disease, earlier use of cystectomy, broader use of chemotherapy and the availability of a dedicated multidisciplinary team.