Selecting initial therapy for bladder cancer

Progress has been made at both ends of the spectrum of bladder cancer. The introduction and increasing use of effective intravesical agents for both treatment and prophylaxis of tumors limited to the mucosa or lamina propria has reduced the incidence and frequency of subsequent tumors. At the other end of the spectrum--patients with locally extensive bladder cancer--neoadjuvant or initial chemotherapy is producing complete and partial responses. Hopefully this will translate into an improvement in the cure rate. In arriving at a decision regarding treatment for a patient with bladder cancer the urologist integrates information derived from a thorough endoscopic examination of the lower urinary tract (bladder and urethra), complete grading and staging of resected tumor including results of mucosal biopsies from suspicious and normal appearing urothelium, and cytology obtained by bladder irrigation. Treatment also may be influenced by such factors as prior history and treatment of bladder cancer and the patient's age and medical status. Assuming no prior bladder tumor history, endoscopic resection/fulguration followed by intravesical therapy will be used for tumors confined to the mucosa (Ta or Tcis) or lamina propria (TI). Optimally the urologist should resect all evident tumor and incorporate the intravesical agent as prophylaxis. Cytology and endoscopy will monitor the success of this approach. If the patient develops another superficial tumor while receiving prophylaxis another intravesical agent can be delivered, possibly using an intensive treatment schedule. Several agents have demonstrated effectiveness both for treatment and prophylaxis. They include mitomycin C, thiotepa, Adriamycin (doxorubicin), and bacillus Calmette-Guerin. The indications for radical cystectomy are invasion into the bladder muscle, tumor extension into the prostatic ducts or prostatic substance, or persistent tumor after an adequate trial of one or more intravesical agents used in conjunction with endoscopic resection. The escalating complete and partial response rates associated with combination chemotherapy of metastatic bladder cancer has led to the use of these regimens before considering cystectomy for patients with locally extensive bladder cancer, e.g., T3, T4, and N1-2. Downstaging with chemotherapy in this group of poor-risk patients may be preferable to the traditional approach of proceeding with exenterative surgery or full-dose radiation and considering chemotherapy later when metastases are evident.