Dr Bochner on the Need for Multimodal Approaches in MIBC

Bernard H. Bochner, MD, FACS, urologic surgeon, Sir Murray F. Brennan Chair in Surgery, Memorial Sloan Kettering Cancer Center, discusses the need for a multimodal approach to the management of muscle-invasive bladder cancer (MIBC).

In the management of MIBC, a multimodal approach often includes either preoperative or postoperative treatment regimens, Bochner begins. Historically, the cornerstone of this approach has been platinum-based chemotherapy, which has demonstrated significant benefits in improving outcomes for patients. Studies conducted throughout the 1990s and early 2000s showed that administering platinum-based chemotherapy before bladder removal could improve survival rates by up to one-third for patients with localized, muscle-invasive tumors, he details.

However, a significant unmet need exists regarding patient eligibility for platinum-based chemotherapy, Bochner states. Approximately 40% of patients with MIBC are not candidates for this treatment due to factors such as renal dysfunction, sensory neural hearing loss, or cardiovascular issues. This limitation has driven the search for alternative agents, he says. Additionally, the use of platinum-based chemotherapy in the neoadjuvant setting can lead to overtreatment, as it is difficult to determine which patients have micrometastatic disease or who will be responsive to platinum-based therapy, Bochner adds.

In response to these challenges, there has been considerable interest in evaluating the efficacy of adjuvant chemotherapy as an alternative to neoadjuvant treatment, Bochner says. The rationale is that if adjuvant chemotherapy can offer similar benefits, it might be a viable option for patients who are not eligible for preoperative chemotherapy, he explains. Although studies investigating adjuvant chemotherapy have struggled with accrual over time, meta-analyses suggest that it may indeed offer comparable benefits, Bochner adds. However, the evidence supporting adjuvant chemotherapy is less robust, with studies being relatively small in scale. Furthermore, like neoadjuvant chemotherapy, adjuvant chemotherapy requires that patients be platinum-eligible, he notes.

Overall, the exploration of both neoadjuvant and adjuvant chemotherapy continues to be crucial in the quest to optimize treatment for MIBC, particularly in light of the limitations associated with platinum-based therapies and the need for alternative strategies that can accommodate a broader patient population, Bochner concludes.