Expert Urges for a More Multidisciplinary Approach to Bladder Cancer Care

Danielle Bucco
Published: Friday, Oct 06, 2017

Robert Jones, MD
Robert Jones, MD
Multidisciplinary teams could help push the quality of care for patients with urothelial carcinoma forward, according to Robert Jones, MD.

“We need to build stronger, more comprehensive, and more specialized multidisciplinary teams,” says Jones, a professor of Clinical Research at the University of Glasgow.

In an interview with OncLive at the 2017 Global Congress on Bladder Cancer held in Edinburgh, United Kingdom, Jones discussed the future treatment landscape for patients with urothelial carcinoma in a more multidisciplinary setting.

OncLive: Can you provide an overview on your presentation about the future of urothelial carcinoma?

Jones: I discussed the future role of the medical oncologist is in the management of advanced urothelial cancer, highlighting 4 key things, which I think are clear in cancer: 

Firstly, early detection brings about better outcomes. As a medical oncologist, we're not diagnosticians, but early detection results in better outcomes. Traditionally, medical oncologists have been involved later in the course of the disease. We've gradually brought that role further forward. Currently, the earliest moment that the medical oncologist is [involved] is in the management of muscle-invasive bladder cancer with neoadjuvant chemotherapy.

It's clear that there are also patients with non-muscle invasive bladder cancer who have a very high risk of dying. Therefore, in the future, the medical oncologists are going to be getting involved in this setting for 2 reasons: Firstly, the current treatments in that situation leave a great unmet need. The toxicity and efficacy of both Bacillus Calmette-Guérin (BCG) and cystectomy are questionable. We badly need new treatments for those very high-risk patients. It may be that drugs play a part in the role of systemic therapy. I think that medical oncologists are going to get involved in that stage of the disease. 

Secondly, it's clear that we're not going to continue treating all patients in the same way. We've failed up until now in trying to subdivide patients. There has been a lot of work around how you select patients for immune checkpoint therapy and that's all failed in bladder cancer. There is a lot of data coming through, particularly from The Cancer Genome Atlas, where we can clearly subdivide patients—there are at least detectable trends in response to treatment. 

There is a lot of work that still needs to be done both with making those biomarkers ready for clinical use and in understanding the actual productivity of those markers. I think it is inevitable in the next few years that we're going to have to better understand the molecular biology [of the disease] because it's going to dictate how we treat bladder cancer, as it already does in other common cancers, such as breast cancer, lung cancer, and colorectal cancer. 

Thirdly, it's clear that bladder cancer at many stages of presentation benefits from multimodality therapy. I think the multidisciplinary team in bladder cancer is poorly developed at an organizational level. We need to build stronger, more comprehensive, and more specialized multidisciplinary teams. The idea that bladder cancer is managed by the urology multidisciplinary team where there are 9 patients with prostate cancer for every 1 patient with bladder cancer, is going to disappear and a multidisciplinary team is going to be focused purely on urothelial cancers. 

Finally, the fourth observation is that the molecular biology of cancer, including bladder cancer, is incredibly complex. This will reflect what I've already said about stratification. Part of our take on data is to do big randomized phase III trials. In a disease like bladder cancer, which is relatively rare, we are beginning to understand that the molecular pathways are not entirely linear. We're going to need to find new ways of making progress as we increasingly subdivide cancer patients. In my opinion, the era of the big randomized phase III trials is something we're going to have to part with over the coming years. 

Is there any ongoing research that you're interested in?

At a scientific level, I think there is a lot of interesting research around gene expression profiling, both at the genomic and transcriptomic levels, which is already beginning to give us a nearly tractable hypothesis. There is also ongoing research to translate those complex biomarkers into simpler biomarkers that are potentially amenable to every pathology laboratory, in every specialist hospital in the world.

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