Treatment of bladder cancer: the present and the future

Abstract

Bladder cancer is one of the most frequent tumours of the urinary tract and the treatment of this malignancy requires close co-operation between urologists and oncologists. The superficial disease is treated with good results with transurethral resections and local immunotherapy or chemotherapy. However, there is a considerable fraction of BCG-refractory tumours (30%) and progression to muscle-invasive cancer. New approaches such as BCG combined with low-dose interferon or recombinant BCG strains are promising but need to be explored in prospective trials. Better understanding of the tumour biology and immunology will probably make it possible select patients with a high risk of progressive disease and to tailor further therapy options.

The cornerstone of muscle invasive tumours treatment is radical cystectomy. The neoadjuvant chemotherapy is a promising option, especially in tumours invading deeply into the bladder wall or infiltrating the surrounding organs, but it require furthers confirmation of the results in phase III trials before introducing it as a standard treatment. However some leading centers have already implemented neoadjuvant chemotherapy in some selected groups of patients (eg. M.D. Anderson). Combined chemotherapy and modern 3-D conformal radiotherapy enable us to preserve the organ and the function of the bladder (bladder conserving therapy) and they are intensively studied in current trials.

In the near future molecular characterisation of individual tumours might help to choose a bladder conserving therapy or cystectomy adopted to a for particular patient. So far, four-drug regimen – MVAC has been widely used in metastatic and locally advanced disease. Recently, it was shown that a combination of gemcitabine and cisplatin (GC) is equally effective but less toxic. New chemotherapies tested in clinical trials include gemcitabine, taxanes and new-class drugs interfering with signal transduction. Individualization of established and experimental treatment options based on molecular tumour characteristics, such as p53 status will probably be the future of bladder cancer pharmacotherapy.