Pre-Surgical Bladder Cancer Treatment: What's Next

Many questions still remain in the treatment of localized bladder cancer, like which patients are best suited to receive neoadjuvant (pre-surgery) chemotherapy — a procedure that could be beneficial, but comes with increased toxicity, according to Brock O’Neil, M.D.

“We need to push hard on finding the patients we know are going to benefit,” O’Neil, who is an assistant professor in the Division of Urology at the University of Utah School of Medicine, said in an interview with OncLive, a sister publication of CURE.

O’Neil mentioned that the data available regarding neoadjuvant treatment with a cisplatin-based chemotherapy is more than two decades old, signaling that this treatment should be offered to most patients who will be undergoing a cystectomy, or bladder removal surgery. However, that is not always the case.

A major issue with receiving pre-surgical chemotherapy is the side effects that it brings — particularly in patients with bladder cancer. Patients with kidney issues probably should not be receiving cisplatin, O’Neil said.

“The clear message that we run into in the community is that there are patients who are not qualifying for cisplatin-based chemotherapy, and they end up getting carboplatin,” he added. “And, we know that is a much inferior approach.”

Finding a biomarker of those who will benefit — and those who will not – from neoadjuvant chemotherapy will be key to moving this field forward.

“If we can identify patients who are less likely to benefit from that, and can move on to timely cystectomy, that would be highly beneficial,” O’Neil said.

Researchers are struggling to answer questions in the post-surgical adjuvant setting, too, due to a lack of patient participation in clinical trials. Cystectomies are major surgeries, and most trials have a slim window after surgical procedures, during which patients must be enrolled.

“There are a lot of challenges to get patients on to that after dealing with postsurgical complications. The trials had very poor accrual and eventually closed.” O’Neil said.

But there are still some significant advances being made in the surgical realm of bladder cancer treatment, such as the use of robotic cystectomy. This is the direction that the field is moving toward, O’Neil said.

Of note, results from the RAZOR trial — a randomized trial comparing open cystectomy with robotic cystectomy – appeared to be promising, he added. Although oncolytic outcomes were almost equivalent in both groups, there was benefit seen when it came to blood loss and length of hospital stay.

“The second thing is that there is a big push for early recovery after surgery protocols,” O’Neil said. “Most centers that are doing cystectomies have those, and those have shown to reduce hospital lengths of stay and may have some impact on complications.”

And after patients come out of surgery, wearable sensors might be a way that health care professionals can tell if their patients are facing complications.

“We could see if fitness trackers, or some kind of wearable device, will give us an idea of who is getting into trouble after surgery earlier, so we can intervene before they have to be readmitted or have a major complication,” O’Neil said.

Looking even farther into this space, O’Neil noted that maybe one day immunotherapy may come into play for the neoadjuvant setting — especially after its success in treating patients with metastatic disease.

“That is farther off, but potentially has a better side effect profile that surgeons would be more interested in and encourage their patients to do that,” he added.