Multidisciplinary care integrating urology, medical oncology, and radiation oncology expertise is the key to providing the best care for patients with metastatic or muscle-invasive bladder cancer, the American Society of Clinical Oncology (ASCO) said in its endorsement of a new clinical practice guideline developed by the European Association of Urology (EAU).
ASCO’s clinical practice guideline committee reviewed the EAU’s recommendations and found them “clear, thorough, based on the most relevant scientific evidence, and ... acceptable to patients.” It endorsed all but one of the EAU’s recommendations, with what it described as only minor qualifications “to better clarify the roles for systemic chemotherapy- and chemoradiotherapy-based organ preservation treatment.”
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By endorsing the EAU’s guideline, ASCO hopes to “increase the number of high-quality, ASCO-vetted guidelines available” to its membership and to all primary-care providers, urologists, radiation oncologists, and medical oncologists, said Dr. Matthew I. Milowsky of the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, and his associates on the ASCO clinical practice guideline committee.
Approximately 5% of all patients newly diagnosed as having bladder cancer present with metastatic disease. Another 30% present with muscle-invasive disease, and approximately half of them will eventually develop distant metastases.
In particular, the ASCO committee agreed that the importance of multidisciplinary care “cannot be overemphasized,” given the lethality of metastatic and muscle-invasive bladder cancer and their severe impact on patients’ quality of life. For example, patients should be referred to a medical oncologist for a discussion of neoadjuvant chemotherapy, and those with muscle-invasive disease should be referred to a radiation oncologist for a discussion of bladder preservation.
ASCO also emphasizes that radiotherapy alone is inferior to chemoradiotherapy in patients receiving bladder-preservation therapy with curative intent, and that chemoradiotherapy should be recommended.
For high-risk patients who haven’t received the recommended neoadjuvant chemotherapy, adjuvant cisplatin-based chemotherapy is an option. But the data are insufficient to consider the use of non-cisplatin-based chemotherapy in the adjuvant setting, Dr. Milowsky and his associates said (J Clin Oncol. 2016 Mar 21. doi: 10.1200/JCO.2015.65.9797).
There is no FDA-approved therapy for patients with metastatic bladder cancer who show disease progression after platinum-based combination chemotherapy. These patients should be encouraged to participate in clinical trials, where they can access promising experimental treatments such as molecular-targeting agents and immunotherapies. Alternatively, they can be offered single-agent therapy such as paclitaxel, docetaxel, or vinflunine where available.
The one recommendation in the EAU guideline that ASCO did not endorse stated that preoperative radiotherapy for muscle-invasive bladder cancer “can result in tumor downstaging after 4-6 weeks.” ASCO’s clinical practice guideline committee determined that the evidence on which the EAU based this recommendation was not sufficient.