Dr Nguyen on Trimodal Therapy in MIBC

Anthony T. Nguyen, MD, PhD, faculty member, Department of Radiation Oncology, Cedars-Sinai Cancer Institute, discusses the methodology of trimodal therapy (TMT) in patients with muscle-invasive bladder cancer (MIBC), as well as disease characteristics that may qualify patients for bladder-preserving treatment.

TMT is an effective treatment approach for patients with MIBC, as it aims to preserve the native bladder and optimize long-term patient outcomes, Nguyen says. The administration of TMT is inherently multidisciplinary, requiring collaboration between urologists, medical oncologists, and radiation oncologists, Nguyen notes. In patients with MIBC, TMT involves the transurethral resection of bladder tumor, which is a maximal endoscopic resection, followed by concurrent chemoradiation targeting both the pelvic lymph nodes and the bladder, Nguyen explains.

This comprehensive treatment approach extends beyond the active phase with a structured follow-up regimen recommended by the National Comprehensive Cancer Network (NCCN), according to Nguyen. Follow-up consists of cystoscopies; imaging with PET-CT scans, CT scans, or MRIs; and urine and blood tests to monitor for potential cancer recurrence, Nguyen emphasizes. Although radical cystectomy remains a standard treatment approach for patients with MIBC, TMT is widely considered an effective alternative and has received a category 1 recommendation from the NCCN for use in eligible patients, Nguyen adds.

Determining the ideal candidates for bladder-preserving treatments involves a multidisciplinary approach, Nguyen explains. Regarding overall tumor burden within the bladder, patients would ideally have a solitary T2 or T3a tumor measuring less than 6 centimeters. Moreover, the presence of tumor-associated hydronephrosis often correlates with tumor burden and may impact the likelihood of patients achieving a complete response with TMT, although this is not a definite contraindication to bladder preservation, Nguyen notes. Achieving visibly complete endoscopic tumor resection is an essential goal of bladder-preserving treatment, although some randomized clinical trials have demonstrated favorable disease-free survival rates upwards of approximately 80% with a biopsy-only approach, Nguyen concludes.