According to Seth P. Lerner, MD, Professor in the Scott Department of Urology at Baylor College of Medicine, Houston, and Co-chair of the session at the Genitourinary Cancers Symposium where the study by Mak and colleagues was presented, the data clearly demonstrate proof of principle that the combined-modality approach to therapy is safe and effective in selected patients with muscle-invasive bladder cancer. However, he cited several caveats, including the small number of patients accrued over 14 years, and the exclusion of patients with hydronephrosis, anemia, and large T3 or T4 tumors. Moreover, even though locoregional control was achieved in the majority (over 70%) of patients and a minority of patients require salvage cystectomy, a significant percentage experienced a non–muscle invasive recurrence in the bladder, necessitating salvage intravesical therapy.

Further, cystectomy is often required in patients who fail to achieve a complete response, as well as in those who develop a recurrence with high-grade non–muscle invasive disease, leaving at most 35% to 40% of patients who are long-term disease-free survivors and have an intact bladder. The chemotherapy regimens used are effective as radiosensitizers and optimize locoregional control but are unlikely to sterilize occult systemic visceral and N2 or N3 nodal metastatic disease. Finally, this is intensive therapy, requires meticulous coordination with the multidisciplinary team, and be can be costly as a result of both the treatment and follow-up intensity, Dr. Lerner noted.

“Despite these limitations, it is hard to argue against the benefit to the patient for bladder preservation. So, can we identify the patients most likely to respond among those without locally advanced disease or those who are not medically fit or refuse cystectomy?” he asked. ■

Disclosure: Dr. Lerner reported no potential conflicts of interest.