Bladder conservation for muscle-invasive bladder cancer

In the UK alone, approximately 10,000 patients are diagnosed with bladder cancer each year. Of these, muscle-invasive bladder cancer stage T2 or T3 accounts for 10-15%, with the remainder being non-muscle-invasive tumors, dealt with by local intravesical treatment. This group of patients are often older, the median age at presentation being 65-70 years and since this is a smoking-associated cancer there are often significant comorbidities. Transitional cell carcinoma is the most common histological type and comprises >90% of bladder cancers. Other cell types include squamous cell carcinoma, adenocarcinoma, small-cell carcinoma, sarcoma, carcinosarcoma, lymphoma and melanoma. In bladder cancer, the most important prognostic factors are stage and grade. Cystectomy, radiotherapy and chemotherapy all have a role in the management of bladder cancer. In many centers across the world, the standard management of muscle-invasive bladder cancer, stage T2 and T3, is radical cystectomy and pelvic lymphadenectomy. There is now increasing evidence that modern nonsurgical approaches using chemoradiation achieve results at least as good as those with surgery and enable bladder preservation in the majority of patients. Optimal chemoradiation schedules and the role of radiosensitizers remain important areas of research to optimize the bladder-preserving approach. Ultimately, a prospective randomized trial is needed to compare modern state-of-the-art surgery with chemoradiation to provide high-level evidence on which informed patient choices can be made.