Jonathan L. Wright, MD, MS, FACS
One of the ongoing challenges faced in localized muscle-invasive bladder cancer is determining whether or not patients are best suited for neoadjuvant chemotherapy, explained Jonathan L. Wright, MD, MS, FACS. He added that proper patient selection ultimately boils down to 2 things: disease stage and cisplatin eligibility.
“Over the past decade, we've seen a significant increase in the utilization of neoadjuvant chemotherapy,” said Wright. “We've seen the increase [in neoadjuvant chemotherapy] nationally, and we favor it for patients who are platinum-eligible.”
For those who are deemed ineligible for neoadjuvant chemotherapy, radical cystectomy is advised. Although some patients may benefit from bladder preservation, this approach should be recommended with caution, he explained.
In an interview during the 2018 OncLive®
State of the Science Summit™ on Genitourinary Cancers, Wright, medical director of the University of Washington Medical Center Urology Clinic, associate professor of Urology at University of Washington, and affiliate investigator at the Fred Hutchinson Cancer Research Center, highlighted the available therapies for patients with localized muscle-invasive bladder cancer.
OncLive: What factors should be considered when managing a patient with bladder cancer?
: First, [we should consider] whether or not a patient should receive neoadjuvant chemotherapy and if they are a candidate for chemotherapy. What are the appropriate choices for them? Second, [we need to look] at patients following radical cystectomy and determine the role of adjuvant chemotherapy [in these patients]. Finally, [we need to determine] who the appropriate patients are for bladder preservation and how we should recommend doing that.
Which patients are appropriate to receive neoadjuvant chemotherapy?
Ideally, we want a patient who is eligible for cisplatin with muscle-invasive or locally advanced T3, T4, and/or node-positive disease; that includes those who have adequate renal function and no significant hearing loss, peripheral neuropathy, etc. The main thing is to identify patients who are primarily eligible for cisplatin based on renal function, as that is the best treatment in the neoadjuvant setting.
Is cisplatin the preferred neoadjuvant chemotherapy?
We looked at carboplatin, too. Although there is response, it is inferior and there's more disease progression in patients in the metastatic and neoadjuvant settings. We're now seeing immunotherapy come in with checkpoint inhibition both alone and also in combination with neoadjuvant chemotherapy. These studies are ongoing.
How does your approach differ for patients who are ineligible for neoadjuvant chemotherapy?
If they’re not eligible for cisplatin-based neoadjuvant chemotherapy, we recommend upfront cystectomy. There are cases where we'll use alternative agents, but, in general, if they're not cisplatin eligible we prefer upfront cystectomy. The use of carboplatin is an inferior option for patients.
Have approaches to radical cystectomy changed in recent years?
Certainly—to date, more cystectomies are being done robotically. I do both robotic and open cystectomies. They are just 2 different ways to take out the bladder. Most importantly, they have similar oncologic efficacy.
How do you decide who should undergo an open cystectomy versus a robotic cystectomy?
We have a lot of operating rooms (ORs) and only a few robots. If a patient needs to have surgery soon, I can get an OR, but I may not be able to get a robot. If they are ever going to get chemotherapy, and we can schedule it 4 months from now, it's easy to plan for a robot. It depends on what the availability is.
What should be emphasized about bladder conservation?
I'm a urologist. I take out bladders for a living, but we greatly underutilize bladder preservation in appropriate patients. Bladder preservation consists of a combination of chemotherapy and radiation. Probably the majority of patients with muscle-invasive bladder cancer are not good candidates. If they have a solitary small lesion that can be completely resected, there is no extensive carcinoma in situ, there's no hydronephrosis, and they don't have significant bladder symptoms, then they may be [a candidate for bladder preservation].