The bladder cancer conundrum is how to accurately determine the type of tumor, treatment, and timing that is ideal for each patient? This is by the use of neoadjuvant chemotherapy (NAC); for muscle‐invasive bladder cancer (MIBC). MIBC is a deadly disease. If untreated, the 2‐year mortality rate is 85% and even if treated the overall survival (OS); the rate at 5 years is 50%. In this context, NAC is appealing because it may improve outcomes.
In 2003, a landmark study by Grossman et al. examined NAC prior to radical cystectomy (RC) for MIBC. The median survival (44 vs 77 months, P = 0.06) and pT0 rates; which equate to the best survival rates (30% vs 15%, P < 0.001); improved with NAC. A meta‐analysis of 11 randomized control trials in >3000 patients reported an OS benefit of 5% at 5 years with platinum‐based NAC.
Important to examine outcomes
Whilst NAC improves outcomes, especially for those patients who achieve pT0; it is also important to examine outcomes for patients with persistent MIBC and to determine if NAC is helpful in those patients. In this attempts to answer this question by examining outcomes for patients with persistent MIBC after RC alone or NAC followed by RC. Using Surveillance, Epidemiology; End Results (SEER)‐Medicare data; the authors examined 1505 patients that underwent RC alone and 381 patients that received NAC.
The authors report that after propensity weighted Kaplan–Meier analysis; the 5‐year OS rate was improved amongst patients that received NAC and RC as compared to patients that had RC alone if there was pT2–T4N0M0 disease; on final pathology (43.5% vs 37.2%, P = 0.001). However, there was no difference in cancer‐specific survival (CSS) for NAC with RC compared to only RC (53.7% vs 58.4%, P = 0.76).
After adjusting for confounders, the authors found similar results. The use of NAC and RC was found to have an OS benefit (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.67–0.94; P = 0.006); for pT2–4N0M0 patients but not a CSS benefit (HR 0.88, 95% CI 0.72–1.08; P = 0.23). In this study, one issue that is raised is the challenges of accurate preoperative staging. The authors in this paper analyzed patients according to the pathological stage to limit confounding; as determining the exact stage of patients prior to NAC and RC cannot do exactly.
Clinical T2 vs T3 disease
In this study, pT2 patients had on OS benefit after NAC but pT3–4 patients did not benefit. Clinical staging relies on transurethral resection, imaging, and examination under anesthesia to establish the diagnosis. Without final staging, it is difficult to precisely parse out which patients are clinical T2 vs T3 disease before RC. Predicting which patients are non‐responders is particularly important because these patients may exposed unnecessarily; to the risks of chemotherapy and may have delays in surgery that can negatively impact their outcomes.
Therefore, even if the optimal treatment is known, identifying which patients will benefit can challenging. Certainly, more work needs to be done. So, what can we do now? they can promote the overall well‐being of our patients. Urologists can conduits to help patients’ live healthy lifestyles and engage in behaviors that will promote psychological stability and physical strength. Encouraging daily activity, increasing fruit and vegetable consumption; if needed, weight loss is options.
The Prehabilitation programmes
Smoking cessation represents an imperative opportunity where urologists can make a positive impact. Prehabilitation programmes focused on preparation for surgery can do during NAC or while waiting for surgery and incorporate these elements. In this way, waiting time is leveraged to make small but cumulative improvements ‘a little bit at a time’ is possible.
For now, they will continue to study the bladder cancer conundrum; subtypes of tumors, various treatments, and the best timing for therapy. Regardless of these results, it is likely patients with bladder cancer will still need some combination of surgery, systematic therapy, and supportive care while they heal. In the interim, promoting well‐being is one way to help patients live healthier lives whilst making them more resilient to undergo whatever treatments may emerge next.