Bladder cancer bladder preservation treatment points list

Introduction Bladder cancer is one of the most common malignant tumors in urology
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According to statistics, there are about 549,393 new cases of bladder cancer in the world every year, and the number of new cases of bladder cancer in China in 2020 was 85,694
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Bladder urothelial carcinoma accounts for about 90% of all bladder malignancies and can be divided into non-muscle-invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC) according to whether it invades the bladder muscle
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Radical cystectomy (RC) is the standard treatment for MIBC
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For high-risk NMIBC, after transurethral resection of bladder tumor (TURBT) combined with Bacillus Calmette-Guérin (BCG) intravesical instillation, RC is also recommended if BCG treatment fails
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In clinical practice, many patients are not suitable for or refuse RC
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Therefore, it is extremely important to find curative and bladder-sparing treatment options other than RC
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Bladder preservation therapy balances tumor control and quality of life to a certain extent, and is an alternative and supplement to RC
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Judging from the application status of bladder preservation at home and abroad, the proportion of domestic MIBC bladder preservation is significantly lower than that of foreign countries
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In terms of efficacy, the effect of bladder-preserving therapy is not inferior to that of RC
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In terms of quality of life, bladder-preserving triple therapy (TMT) has certain advantages
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From the cost-effectiveness analysis, TMT is better than RC
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Bladder-preserving therapy for MIBC patients Choosing MIBC bladder-preserving therapy requires comprehensive consideration of two factors, namely patient factors and tumor factors
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Recommendation 1 for MIBC bladder-preserving treatment plan: For MIBC patients who are not suitable for RC or who are willing to undergo bladder-conserving treatment, it is recommended to formulate a bladder-conserving treatment plan after discussion with the MDT team and be responsible for the full understanding of the relevant risks and possible benefits.
implemented (Figure 3)
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Recommendation 2: Bladder preservation therapy for MIBC patients should consider the dominant patient types (Table 1), and conduct a comprehensive evaluation by the MDT team
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Recommendation 3: Based on the current research evidence and relevant practical experience, the most commonly used clinical regimens for bladder-preserving therapy for MIBC patients include: TMT based on maximized TURBT and concurrent chemoradiotherapy; based on TURBT + chemotherapy (including intravenous chemotherapy or arterial infusion) Chemotherapy) bladder-preserving regimen; bladder-preserving regimen based on evaluation of cCR after neoadjuvant therapy; immunotherapy also has some evidence in the exploration of bladder-preserving therapy
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The above programs have their own advantages and disadvantages, and there are still some controversies in patient selection and efficacy evaluation
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Recommendation 1: For patients with recurrence of NMIBC, TURBT combined with intravesical instillation can be selected.
For patients with high risk factors, salvage RC should be preferred
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Recommendation 2: For patients with recurrence at stage T1 or above who have the opportunity for surgery, salvage RC should be the first choice
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Recommendation 3: For patients with recurrence and metastasis, systemic treatment should be performed according to inoperable or metastatic disease
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Bladder-preserving therapy for NMIBC patients chooses high-risk NMIBC.
The standard treatment after TURBT is BCG intravesical instillation.
However, when BCG infusion fails, RC or bladder-preserving therapy should be considered according to the patient's individual conditions.
If the patient is not suitable for or refuses RC, bladder preservation can be selected treatment
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Recommendation 1 for bladder-preserving therapy for NMIBC: For NMIBC patients with BCG perfusion failure or non-response, RC or bladder-preserving therapy should be comprehensively considered according to the individual conditions of the patient
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For NMIBC patients who are willing to take bladder-preserving therapy, it is recommended to formulate a bladder-preserving therapy plan after discussion with the MDT team and be responsible for its implementation under the condition of fully understanding the related risks and possible benefits.
See Figure 4 for details
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Recommendation 2: Maximizing TURBT is still the main surgical treatment for bladder preservation.
Alternative options for adjuvant drug therapy with relevant clinical evidence include: intravesical instillation; PD-1/PD-L1 monoclonal antibody-based immunotherapy
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Recommendation 3: Patients should be followed closely during bladder conservation therapy
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Recommendation 1: For patients with low-grade recurrence, the current treatment can be continued
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Recommendation 2: For patients with high-grade or invasive cancer recurrence, RC is the first choice.
If the patient is not suitable for or refuses RC, it is recommended to participate in clinical trials or refer to MIBC bladder preservation strategy
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Recommendation 3: For patients with recurrence and metastasis, systemic treatment should be performed according to inoperable or metastatic disease
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Patients with bladder preservation therapy need to have good treatment compliance and be able to do regular follow-up and reexamination
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The whole-process management of patients through MDT can enhance the patient's cognition of the disease and the process of bladder-preserving therapy, thereby improving the success rate of bladder-preserving therapy
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Bladder-sparing therapy is a necessary complementary treatment option for patients who are not suitable for or refuse RC
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For MIBC patients who meet the predominant patient criteria, bladder-sparing therapy can significantly improve the patient's quality of life and achieve a long-term prognosis similar to RC
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Bladder-sparing therapy has also shown promise for patients with failed or unresponsive BCG perfusion
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Bladder-preserving therapy involves the research and collaboration of MDT, and we need to continuously optimize methods and technologies to find more new drugs and predictive indicators to improve the efficacy of bladder-preserving therapy for bladder cancer
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Reference: Urological Oncology Collaborative Group of China Cancer Hospital.
Chinese consensus on multidisciplinary diagnosis and treatment of bladder cancer and bladder preservation therapy [J].
Chinese Journal of Oncology, 2022, 44(3):209-218.
Editor: LR Reviewer: XY Execution: LR