Current approaches to the management of bladder cancer in older patients

Bladder cancer is largely a disease of older adults, with nearly half of diagnoses occurring in those older than age 75. This has led to a disconnect between the efficacy and effectiveness of various treatment strategies. For example, surgical removal of the bladder is a potentially curative approach to muscle-invasive disease, although the large single-center and multicenter series that have established the efficacy of this approach include only a small proportion of older patients. Similarly, clinical trials that have established optimal chemotherapeutic regimens for use in the perioperative and metastatic settings comprise largely younger patients. Extrapolating the available evidence to the population of older patients with bladder cancer requires careful assessment of an individual patient's functional status and comorbidities to estimate the likelihood of treatment-related harms. This should be coupled with an understanding of an individual patient's goals of therapy, independence, estimated longevity, and social support to facilitate a shared medical decision regarding treatment. The use of validated approaches to geriatric assessment may refine risk stratification in older adults, although practical challenges have prevented uniform adoption in routine clinical practice.