Jonathan L. Wright, MD, MS, FACS, medical director of the University of Washington Medical Center Urology Clinic, associate professor of urology at University of Washington, and affiliate investigator at the Fred Hutchinson Cancer Research Center, discusses frontline considerations in patients with locally advanced, muscle-invasive bladder cancer.

The first decision that has to be made is whether or not the patient should receive neoadjuvant chemotherapy and if they are a candidate for chemotherapy, says Wright. Patients who undergo radical cystectomy must be carefully monitored following the procedure to determine the role of adjuvant chemotherapy. Determining whether or not a patient qualifies for bladder preservation is another component of care in this setting.

In terms of selection criteria for neoadjuvant chemotherapy, patients should be eligible for cisplatin with muscle-invasive or locally advanced T3, T4, and/or node-positive disease; that includes those who have adequate renal function and no significant hearing loss, peripheral neuropathy, says Wright. The main factor is to identify patients who are primarily eligible for cisplatin based on renal function, as that is the best treatment available in the neoadjuvant setting, Wright concludes.

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Dr. Wright on Frontline Considerations in Locally Advanced Bladder Cancer

Jonathan L. Wright, MD, MS, FACS, medical director of the University of Washington Medical Center Urology Clinic, associate professor of Urology at University of Washington, and affiliate investigator at the Fred Hutchinson Cancer Research Center, discusses unmet needs in muscle-invasive bladder cancer.

From a clinical perspective, the biggest unmet need in muscle-invasive bladder cancer is determining which patients will respond to neoadjuvant chemotherapy, says Wright. Physicians know that the approach results in improved survival; however, not all patients are going to respond to the therapy. Ongoing research is evaluating features of the tumor itself as well as gene expression for potential predictors of response, adds Wright.

Further, investigators are looking at the individual patient to determine if they harbor certain mutations that might make them more or less sensitive to cisplatin. That way, physicians can identify not only the patients with the highest chance for response, but those in whom chemotherapy should be avoided, says Wright.

Physicians also need to adopt more of a multidisciplinary approach in the management of patients with bladder cancer, he adds. That approach involves collaboration between urologists, medical oncologists, and radiation oncologists. He adds that more work needs to be focused on survivorship. Because bladder cancer is the most expensive cancer from diagnosis to death, guiding patients and their families on coping with the disease is a critical aspect of care that needs to be better addressed, concludes Wright.

Dr. Wright on Unmet Needs in Muscle-Invasive Bladder Cancer

Jonathan L. Wright, MD, MS, FACS, medical director of the University of Washington Medical Center Urology Clinic, associate professor of Urology at University of Washington, and affiliate investigator at the Fred Hutchinson Cancer Research Center, discusses the underutilization of bladder preservation in patients with localized bladder cancer.

Urologists acknowledge that bladder preservation is greatly underutilized in appropriate patients, says Wright. Bladder preservation consists of a combination of chemotherapy and radiation. Although the majority of patients with muscle-invasive bladder cancer are not good candidates for the procedure, there are a select few who may qualify, he explains.

For example, a patient with a solitary small lesion that can be completely resected may be a candidate for bladder preservation. In addition, those with no evidence of extensive carcinoma in situ, those without hydronephrosis, and those without significant bladder symptoms, could also be potential candidates for this approach.

Dr. Wright on the Underutilization of Bladder Preservation in Localized Bladder Cancer

Jonathan L. Wright, MD, MS, FACS, medical director, Urology Clinic, University of Washington Medical Center, affiliate investigator, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, discusses the role of immunotherapy in the treatment of patients with bladder cancer.

Over the past few years, immunotherapy has made a significant impact in the treatment of upper tract urothelial and bladder cancers. Primarily, checkpoint inhibitors are being used upfront in the metastatic setting for patients with bladder cancer who are ineligible to receive cisplatin-based chemotherapy. Ongoing work is being done to see if immunotherapy has a role in the neoadjuvant setting and in patients with nonmuscle—invasive disease, Wright says.

In 2018 alone, there were 7 FDA approvals for immunotherapy agents in bladder cancer—5 drugs in the second-line setting for recurrent patients and 2 for frontline therapy; however, these checkpoint inhibitors have not yet been tested head-to-head in clinical trials.

Jonathan L. Wright, MD, MS, FACS, medical director, Urology Clinic, University of Washington Medical Center, affiliate investigator, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, discusses immunotherapy in bladder cancer.

Jonathan L. Wright, MD, MS, FACS

Articles

Dr. Wright on Frontline Considerations in Locally Advanced Bladder Cancer

Dr. Wright on Unmet Needs in Muscle-Invasive Bladder Cancer

Dr. Wright on the Underutilization of Bladder Preservation in Localized Bladder Cancer

Dr. Wright Discusses Immunotherapy in Bladder Cancer