Updates and prospects in bladder cancer

15 November 2014

Developments and prospects in bladder cancer treatment were examined at the 6th European Multidisciplinary Meeting on Urological Cancers (EMUC) in Lisbon, Portugal with experts assessing the efficacy of new imaging tools and the options on how to further refine surgical procedures such as minimally invasive radical cystectomy.
Bladder cancer is considered as the fifth most common malignancy in males in western countries and is characterized by frequent recurrence of superficial tumours. Smoking is known as one of the risk factors with males often diagnosed with the disease compared to females (3 to 1 ratio).

In the second plenary session yesterday, Gertraud Heinz-Peer (AT) discussed imaging procedures in bladder cancer and new approaches in the evaluation of haematuria, the strengths of new imaging techniques such as PET-CT and multi-detector computed tomography urography (MDCTU).

Regarding MDCTU, Heinz-Peer said this tool provides high quality multi-planar reformations (MPRs) and 3D reconstructions including virtual cystoscopic views, and has excellent detection rates including lesions less than 5mm. However, MDCTU has low sensitivity for Tis/Ta lesions and does not provide biopsy,

In her concluding remarks, Heinz-Peer said there is clear advantage in the use of MDCTU and flexible cystoscopy as a triage test for rigid cystoscopy and follow-up, while noting that there is a 17% reduction of flexible cystoscopies. She added that the sensitivity of voided urine cytology is inferior to CT-Ultrasound and flexible cystoscopy.

Carl Magnus Annerstedt (SE) spoke on the role of minimally invasive radical cystectomy such as robot-assisted radical cystectomy (RARC), and said the procedure is safe and yields similar results as open radical cystectomy. He added that intracorporeal diversion in RARC procedure is truly minimal. However, he stressed that standardization is important in RARC, adding that this minimally invasive technique is “here to stay.”

On the issues of bladder preserving strategies, Robert Huddart (GB) emphasized that radiotherapy has now wider appeal to patients who want to preserve their bladder and sexual functions. Moreover, radiotherapy offers the option to avoid major surgery particularly in elderly patients and those with co-morbidities.

However, he noted that there is need to carefully select patients who can benefit from radiotherapy. He mentioned patients with single, small tumours as suitable candidates and those who have limited or no carcinoma in-situ (CIS), good bladder function, no renal obstruction and are fit. In his centre, Huddart said they use a template wherein the concept of bladder preservation plays a key role, but in cases where the patient is deemed to be unfit for bladder preservation, surgery is thus recommended.

“There is a feeling that surgery is the only way to go. But if you have a proper discussion with patients, it (radiotherapy) can be an acceptable option to many, “ said Huddart during the Q&A and in response to a query on why radiotherapy is not widely accepted as an option in bladder cancer management.

In the last presentation Torben Orntoft (DK) gave an overview on the translational approach to the management of bladder cancer and noted the core challenges such as identifying which tumour will recur, how physicians can simplify the follow-up process, which tumour will progress, and in case of muscle invasive cancers, which bladder tumours will benefit from cystectomy and which one from radiation therapy. He discussed the work being done on surveillance markers and is optimistic that current research will eventually yield a considerable amount of insightful data.

“Genomic-wise, bladder cancer is a very complex disease. But we are hope that big data will be coming,” said Orntoft.