Systemic chemotherapy in the management of bladder cancer

The treatment of bladder cancer is in a state of evolution. With the advent of effective chemotherapy, multimodal treatment planning is needed to ensure the best results. This requires the participation of the urologist, medical oncologist, radiologist, and radiation therapist in order to determine the optimal treatment strategy for each patient. Currently, radical cystectomy should be considered standard therapy. Neoadjuvant or true adjuvant chemotherapy are still investigational. Randomized trials should be designed to define those patients who will benefit from combined modality therapy, the sequence in which it should proceed, and its impact on disease-free and total survival. Certain principles in patient management require emphasis. 1. The patient must be carefully staged prior to treatment and later restaged thoroughly; whenever possible pathologic confirmation is recommended. Following chemotherapy, all sites of measurable and evaluable disease should be reassessed. Patients with residual masses may have only fibrosis, or microscopic tumor, and complete resection may result in prolonged disease-free survival. 2. Cystectomy after chemotherapy appears to be indicated when this is the only site of disease. If a patient responds systemically with a CR, but has residual disease in the bladder, salvage cystectomy may translate into a prolonged survival. Similarly, a patient who relapses in the bladder following chemotherapy should have surgery. It is unclear if patients with initially unresectable disease who are downstaged (PR) to a resectable lesion should undergo surgery or be consolidated with radiation therapy. 3. Adequate renal function is needed to give optimal doses of chemotherapy. Patients with ureteral obstruction often benefit from a nephrostomy tube. The creatinine clearance may improve following urinary diversion to allow full-dose chemotherapy.