Matthew I. Milowsky, MD
Cheryl T. Lee, MD
As reported in the Journal of Clinical Oncology by Matthew I. Milowsky, MD, of the University of North Carolina Lineberger Comprehensive Cancer Center, and colleagues,1 ASCO has endorsed the European Association of Urology clinical practice guideline on muscle-invasive and metastatic bladder cancers, which was published in European Urology2 in 2014 and updated online in 2015.3 Endorsement was based on review by an ASCO expert panel, co-chaired by Dr. Milowsky and Cheryl T. Lee, MD, of the University of Michigan, Ann Arbor.
The key guideline recommendations are reproduced here, with ASCO qualifications shown in bold italics.
Multidisciplinary input via tumor board discussions and/or directed consultations is critical to the optimal management of patients with muscle-invasive and metastatic bladder cancers (eg, referral to a medical oncologist should be made for a discussion of neoadjuvant chemotherapy and referral to a radiation oncologist for a discussion of bladder preservation in patients with muscle-invasive disease). Implementation of these guidelines requires the integration of urology and medical and radiation oncology expertise to provide the highest level of care to patients.
Neoadjuvant chemotherapy is recommended for T2–T4a, cN0M0 bladder cancer and should always be cisplatin-based combination therapy.
Neoadjuvant chemotherapy is not recommended in patients who are ineligible for cisplatin-based combination chemotherapy, unless the goal is downstaging surgically unresectable tumors.
Any decision regarding bladder-sparing or radical cystectomy in elderly/geriatric patients with invasive bladder cancer should be based on tumor stage, bladder function, and the ability to tolerate major surgery, radiotherapy, and/or chemotherapy.
Radical cystectomy is recommended in T2–T4a, N0M0 and high-risk non–muscle invasive bladder cancer. Chemoradiotherapy-based organ preservation treatment may be offered to select patients with muscle-invasive bladder cancer.
In patients being treated with bladder-preservation therapy with curative intent, combined chemoradiotherapy is superior to, and is recommended over, radiotherapy alone.
In patients being treated with bladder-preservation therapy with curative intent, combined chemoradiotherapy is superior to, and is recommended over, radiotherapy alone.— Matthew I. Milowsky, MD, and colleagues
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Although neoadjuvant chemotherapy is recommended, adjuvant chemotherapy may be offered to high-risk patients who have not received neoadjuvant treatment.* [The ASCO panel notes: “The word “offered” should be interpreted as having a detailed discussion with the patient about the risks and benefits of adjuvant chemotherapy. The discussion should include a thorough review of the absolute risk of recurrence in light of the pathologic findings, acknowledging the limitations of the data in the adjuvant setting.”]
First-line treatment of fit patients with metastatic disease: Use cisplatin-containing combination chemotherapy with gemcitabine plus cisplatin, MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin), or high-dose MVAC with granulocyte colony-stimulating factor.
First-line treatment in patients ineligible (unfit) for cisplatin: Use carboplatin combination chemotherapy or single agents.
In patients experiencing progression after platinum-based combination chemotherapy for metastatic disease, entry into a clinical trial is preferred. Alternatively, single-agent therapy may be offered (eg, paclitaxel, docetaxel, or vinflunine where available). ■
Disclosure: Dr. Milowsky has received research support from Mirati Therapeutics, Pfizer, Cerulean Pharma, Merck, Seattle Genetics, Acerta Pharma, BioClin Therapeutics, and Roche/Genentech.
1. Milowsky MI, Rumble RB, Booth CM, et al: Guideline on muscle-invasive and metastatic bladder cancer (European Association of Urology guideline): American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol. March 21, 2016 (early release online).
3. European Association of Urology: Muscle-invasive and Metastatic Bladder Cancer Guidelines. Available at http://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/. Accessed May 13, 2016.
The bottom line is that these two groups have produced a commonsense, evidence-based manifesto that guides clinicians to provide the correct treatment of advanced bladder cancer, based on evidence rather than rhetoric and hype.— Derek Raghavan, MD, PhD, FACP, FRACP, FASCO