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Organ preservation in bladder cancer: an opportunity for truly personalized treatment

Nature Reviews Urology volume 16, pages 511–522 (2019)Cite this article

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Abstract

Radical treatment of many solid tumours has moved from surgery to multimodal organ preservation strategies combining systemic and local treatments. Trimodality bladder-preserving treatment (TMT) comprises maximal transurethral resection of the bladder tumour followed by radiotherapy and concurrent radiosensitizing treatment, thereby sparing the urinary bladder. From the patient’s perspective, the choice of maintaining quality of life without a negative effect on the chances of cure and long-term survival is attractive. In muscle-invasive bladder cancer (MIBC), the evidence shows comparable clinical outcomes between patients undergoing radical cystectomy and TMT. Despite this evidence, many patients continue to be offered radical surgery as the standard-of-care treatment. Improvements in radiotherapy techniques with adaptive radiotherapy and advances in imaging translate to increases in the accuracy of treatment delivery and reductions in long-term toxicities. With the advent of novel biomarkers promising improved prediction of treatment response, stratification of patients for different treatments on the basis of tumour biology could soon be a reality. The future of oncological treatment lies in personalized medicine with the combination of technological and biological advances leading to truly bespoke management for patients with MIBC.

Key points

  • Retrospective analyses show that appropriately selected patients with muscle-invasive bladder cancer undergoing trimodality bladder-preserving treatment and radical cystectomy have comparable treatment outcomes.

  • Advancements in adaptive and image-guided radiotherapy techniques have improved the accuracy of treatment delivery.

  • Biomarkers have the potential to aid treatment decisions; prognostic biomarkers might help to inform the need for treatment intensification whereas predictive biomarkers might have a role in specific treatment selection.

  • A scientific approach to treatment stratification will enable truly bespoke management plans, empowering patients to make informed decisions, and could influence long-term outcomes and quality of life.

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Fig. 1: Adaptive radiotherapy with the POD strategy.
Fig. 2: Comparison of CBCT and MRI images of the pelvis.
Fig. 3: Putative algorithm for personalized treatment with validated biomarkers.

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Acknowledgements

A.C. and P.J.H. are supported by the NIHR Manchester Biomedical Research Centre.

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Authors and Affiliations

  1. Manchester Cancer Research Centre, Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK

    Yee Pei Song, Alan McWilliam, Peter J. Hoskin & Ananya Choudhury

  2. Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester, UK

    Yee Pei Song, Alan McWilliam & Ananya Choudhury

  3. Mount Vernon Cancer Centre, Northwood, Middlesex, United Kingdom

    Peter J. Hoskin

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  1. Yee Pei Song
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Y.P.S. researched data for the article. All authors made substantial contributions to discussion of the article contents, wrote the manuscript and reviewed and/or edited the manuscript before submission.

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Correspondence to Yee Pei Song.

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Song, Y., McWilliam, A., Hoskin, P. et al. Organ preservation in bladder cancer: an opportunity for truly personalized treatment. Nat Rev Urol 16, 511–522 (2019). https://doi.org/10.1038/s41585-019-0199-x

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