Dr Desai on the Benefits and Limitations of Bladder Preservation With Chemoradiation in MIBC

Neil Desai, MD, MHS, associate professor, director, Clinical Research, Department of Radiation Oncology, Dedman Family Scholar in Clinical Care, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, discusses the potential benefits and limitations of utilizing chemoradiation or triple modality therapy for bladder preservation in the upfront management of patients with locally advanced, nonmetastatic muscle-invasive bladder cancer (MIBC).

Determining whether bladder preservation is the optimal management strategy for patients with locally advanced, nonmetastatic MIBC can be challenging, especially when considering a patient's comorbidities and the extent of disease beyond the bladder, Desai begins. Accordingly, the decision to pursue bladder preservation in place of radical cystectomy necessitates a thorough discussion with patients concerning the importance of quality of life and the risks associated with this procedure.

In a presentation at a recent OncLive® State of the Science Summit™, Desai expanded on a case study of locally advanced bladder cancer invading the cervix of a woman with comorbid renal dysfunction.

In this unconventional case, the patient had both a high risk of distant relapse and high comorbidity-related morbidity and mortality, Desai details. These conflicting priorities complicated the decision-making process, he explained.

Reserarch suggests that the standard management approach of cisplatin-based chemotherapy prior to cystectomy might not be suitable for patients who can tolerate neoadjuvant gemcitabine–and carboplatin-based chemotherapy despite their comorbidities, Desai reports. However, the patient had cervical cancer and cervical invasion in addition to bladder cancer. This feature indicates that the patient is a less optimal candidate for bladder preservation due to the challenges in monitoring outcomes when disease extends beyond the bladder, Desai says.

Ultimately, chemoradiation should be considered a reasonable initial therapy option for this patient, with the acknowledgment of potentially higher failure rates and increased morbidity compared with more localized cases, Desai states. The limitations of relying solely on imaging and cystoscopy for surveillance when disease involves areas beyond the bladder were also recognized, he adds. Overall this case study reinforces the importance of balancing the need for definitive treatment, which can alleviate local morbidity and reduce overall mortality risk, with the patient's ability to tolerate therapy, Desai concludes.