A multidisciplinary approach in muscle-invasive disease: novel chemotherapy combinations and targets in...

The basic management of bladder cancer has changed depressingly little in the last 20 years, with a largely unquestioning acceptance of the role of surgery as the standard of care despite a rising mean age at diagnosis, now well into the mid-70s, meaning many patients will be high risk for a major surgical procedure. Overall survival rates for those diagnosed with bladder cancer have not improved for many years. There is a growing body of studies demonstrating the safety and efficacy of bladder preservation with combined chemo-radiation with good long-term function after such treatment. Two recent studies from the United Kingdom compared radiation alone with sensitized radiotherapy using distinct strategies, one (BCON) focusing on trying to improve tumor oxygenation, one (BC2001) using the combination of 5FU and mitomycin C. Importantly, both studies collected data on late toxicity and showed both good function and low rates of serious side effects with no increase with radio-sensitization. Furthermore, there is good evidence that survival after salvage cystectomy is similar to that seen after primary surgery, suggesting a strategy of primary chemo-radiation with salvage surgery (as used, for example, in anal cancer) may be both rational and safe. This article reviews the evidence on outcomes with chemo-radiation and calls for a rethink in our approaches to this major cancer killer.