A 75-Year-Old Woman with High-Risk Muscle Invasive Bladder Cancer - Episode 2

Standard of Care for Muscle-Invasive Bladder Cancer

Dr. Karim Chamie details the available primary and adjuvant treatments for muscle invasive bladder cancer.

Karim Chamie, MD: The standard of care for patients with muscle-invasive bladder cancer is neoadjuvant chemotherapy followed by either radiation or a radical cystectomy. The decision to pursue one versus the other is dependent upon the patient, their quality-of-life preferences, the tumor biology, and underlying symptomatology of the patient. For instance, to be a good candidate for radiation therapy, patients should have solitary tumors, no evidence of carcinoma in situ, no evidence of extravesical disease or hydronephrosis, and usually no variant histology. Patients who are good candidates for radical cystectomy are the counter: patients that have multifocal disease, variant histology, carcinoma in situ, evidence of hydronephrosis or extravesical extension. With regards to patients who receive radiation therapy, most of those patients go on and complete their radiation therapy. There is about a 29% chance that patients who have undergone radiation therapy would ultimately go on to getting a cystectomy. Now, that's based on historical series from Mass General, by William Shipley's research group. We think that that incidence of needing a cystectomy has gone down, as some of those patients that went on to get a radical cystectomy after radiation were likely non-muscle-invasive recurrences. Those patients may be adequately treated with intravesical therapy.

We assess risk as far as a need or access to chemotherapies based on their performance status, on their renal function, and on hearing loss if any. Determination of getting a cystectomy and variant histologies is based on performance status, their ability to catheterize themselves if they need to, whether the urethra is involved, and tumor biology. As far as radiation therapy, a patient may not be a good candidate if they've had, aside from tumor biology, prior radiation to the pelvis.

Patients who undergo radical cystectomy may require adjuvant therapy, which is a therapy that is based on tumor biology discovered at the time of radical cystectomy. For instance, if a patient has a positive margin, which is unusual, in the urethra or in the bladder neck or around the bladder, they may benefit from radiation therapy. If patients have had neoadjuvant chemotherapy, and at the time of cystectomy they were found to have muscle-invasive disease or node-positive disease, they may be good candidates for adjuvant immunotherapy. If patients didn't have neoadjuvant chemotherapy and were found to have T3 disease or higher, basically extravesical disease or node-positive disease at the time of cystectomy, they may be good candidates for adjuvant therapy with either chemotherapy or adjuvant immunotherapy. The decision to pursue adjuvant chemotherapy versus adjuvant immunotherapy is dependent upon their kidney function status, whether they've had previous neoadjuvant chemotherapy, hearing loss, renal function, and other factors.

Transcript edited for clarity.

Case: A 75-Year-Old Woman with High-Risk Muscle Invasive Bladder Cancer

Initial presentation

  • A 75-year-old woman with gross painless hematuria in August 2020

Patient history

  • Diabetes and hypertension, both of which are managed with medications
  • Current smoker 10 pack/year
  • ECOG PS 0
  • No family history of bladder cancer

Clinical workup and imaging

  • eGFR 56 mL/min
  • Patient undergoes TURBT and is found to have muscle invasive bladder cancer (MIBC)
  • Patient undergoes chest, abdominal and pelvic imaging and a 1 cm external iliac lymph node is identified
  • Clinical stage T3N1M0 urothelial carcinoma

Treatment

  • Patient undergoes neoadjuvant treatment with gemcitabine + cisplatin for 4 cycles, followed by radical cystectomy in Jan. 2021.
  • Patient undergoes imaging and lab work to monitor for disease progression.