Case-Based Review

Urothelial Carcinoma: Muscle-Invasive and Metastatic Disease

2018 July/August;13(4):23-36

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Prognosis

Case Conclusion

After returning home, the patient discusses his complicated medical course with his oncologist. Given his continued high quality of life with good functional status, he requests to continue with therapy for his metastatic bladder cancer and is interested in joining a clinical trial. He is referred to a nearby academic center with openings in a clinical trial for which he would be eligible. In the meantime, his oncologist guides him through filling out an advance directive and recommends that he make an appointment with palliative care services to ensure adequate home support for any future needs he may have.

What is the estimated 5-year survival rate for patients with metastatic bladder cancer?

Overall, prognosis in patients with metastatic bladder cancer remains poor. Median survival in patients being treated with multi-agent chemotherapy is approximately 15 months,^38,40 with an expected 5-year survival of just 15%. This is much improved, however, as prior to the advent of modern chemotherapy estimated survival was just 6 months with metastatic bladder cancer. Importantly, these figures do not take into account the recent advancements with immunotherapy, and thus it is reasonable to assume survival rates may continue to improve. In light of these recent advances, it is strongly recommended that whenever possible patients and clinicians consider participation in clinical trials to continue uncovering new and better therapies moving forward.

A number of tools have been developed to help risk stratify patients based on comorbidity, performance status, and other characteristics, but none have been universally adopted.^57–60 As with many other malignancies, performance status is an important predictor of clinical outcomes in these patients.^61–63Sites of metastasis also may serve to suggest the course of disease. Patients with visceral metastases typically exhibit significantly worse disease with a shortened survival. The role of molecular factors as prognostic markers in bladder cancer is still under investigation. Many biomarkers are being considered (including mutations and polymorphisms in p53, ERCC1, and ERCC2), and evidence suggests some may have a role in prognosis; thus far, none have been validated as prognostic or predictive tools in urothelial carcinoma.

Conclusion

Bladder cancer includes an aggressive group of genitourinary tract malignancies, of which urothelial carcinoma is by far the most common in the Western world. Cisplatin-based therapy remains a mainstay of treatment for eligible patients with both localized and metastatic disease, but immunotherapies have provided a new and promising tool to use in the setting of progressing malignancy. The individual impact of these agents on OS is still being examined. Further studies and ongoing participation in clinical trials whenever possible continue to be essential to the discovery of future treatment options for this highly aggressive disease.