From the Guidelines
Bladder cancer prognosis is highly dependent on the stage at diagnosis, with 5-year survival rates ranging from 95% for non-muscle invasive bladder cancer (NMIBC) to 5% for metastatic bladder cancer (MIBC) 1. The prognosis for bladder cancer is influenced by several factors, including tumor grade, lymph node involvement, presence of carcinoma in situ, patient age, overall health status, and response to treatment. According to the European Association of Urology guidelines, treatment approaches vary by stage, with early-stage cancers often managed with transurethral resection followed by intravesical therapy, while advanced cases may require radical cystectomy, chemotherapy, radiation, or immunotherapy 1.
Key Factors Influencing Prognosis
- Tumor grade: High-grade tumors tend to be more aggressive and have higher recurrence rates 1
- Lymph node involvement: Presence of lymph node metastasis significantly worsens the prognosis 1
- Presence of carcinoma in situ: Increases the risk of recurrence and progression 1
- Patient age and overall health status: Older patients and those with comorbidities may have poorer outcomes 1
- Response to treatment: Patients who respond well to initial treatment tend to have better prognosis 1
Treatment Approaches
- Early-stage cancers: Transurethral resection followed by intravesical therapy (such as BCG immunotherapy) 1
- Advanced cases: Radical cystectomy, chemotherapy (gemcitabine/cisplatin), radiation, or immunotherapy (pembrolizumab or atezolizumab) 1
- Systemic treatment of advanced or metastatic disease: Cisplatin-containing combination chemotherapy, carboplatin and gemcitabine, or immune checkpoint inhibitors 1
Surveillance and Follow-up
- Regular follow-up with cystoscopy and imaging is essential due to bladder cancer's high recurrence rate 1
- Surveillance typically scheduled every 3-6 months initially, then extending to annual checks after several years without recurrence 1
- CT scan every 6 months until the third year, with annual imaging thereafter, including the upper urinary tract (UUT) 1
From the FDA Drug Label
The trial demonstrated statistically significant improvements in OS, PFS, and ORR for patients randomized to KEYTRUDA in combination with enfortumab vedotin as compared to platinum-based chemotherapy.
Table 75: Efficacy Results in KEYNOTE-A39
Endpoint KEYTRUDA 200 mg every 3 weeks in combination with Enfortumab Vedotin Cisplatin or carboplatin with gemcitabine OS Number (%) of patients with event: 133 (30%) Number (%) of patients with event: 226 (51%) | Median in months (95% CI): 31.5 (25.4, NR) | Median in months (95% CI): 16.1 (13.9,18.3) | Hazard ratio* (95% CI): 0.47 (0.38,0.58) | | p-Value†: <0.0001 |Table 76: Efficacy Results in KEYNOTE-869, Combined Dose Escalation Cohort, Cohort A, and Cohort K
Endpoint KEYTRUDA in combination with Enfortumab Vedotin Confirmed ORR (95% CI) 68% (58.7,76.0) Complete response rate 12% Partial response rate 55% Table 77: Efficacy Results in KEYNOTE-052
Endpoint KEYTRUDA 200 mg every 3 weeks Objective Response Rate ORR (95% CI): 29% (24,34) | Complete response rate: 10% | Partial response rate: 20%Duration of Response | Median in months (range): 33.4 (1.4+, 60+
The prognosis for bladder cancer patients treated with pembrolizumab (KEYTRUDA) in combination with enfortumab vedotin is favorable, with:
- Improved overall survival (OS): 31.5 months (95% CI: 25.4, NR) compared to 16.1 months (95% CI: 13.9,18.3) with platinum-based chemotherapy.
- Improved progression-free survival (PFS): 12.5 months (95% CI: 10.4,16.6) compared to 6.3 months (95% CI: 6.2,6.5) with platinum-based chemotherapy.
- Higher objective response rate (ORR): 68% (95% CI: 58.7,76.0) compared to 44% (95% CI: 40,49) with platinum-based chemotherapy.
- Longer duration of response: median 22.1 months (range: 1.0+ to 46.3+) and 33.4 months (range: 1.4+, 60+) in different studies 2.
From the Research
Bladder Cancer Prognosis
- The prognosis for bladder cancer patients has been improving with the development of new treatments, including immunotherapies 3.
- Studies have shown that complete transurethral resection of bladder tumor (TURBT) prior to neoadjuvant chemotherapy can improve survival and oncologic outcomes in patients with muscle-invasive bladder cancer 4, 5.
- Radical transurethral resection of bladder tumor (TURBT) can be an effective treatment option for organ-confined muscle-invasive bladder cancer, allowing for bladder preservation in some patients 6.
- A study on conservative treatment with TURB, neoadjuvant chemotherapy, and radiochemotherapy found that patients with T2 stage and complete histologic resection in initial TURB had the best outcome, with a high overall survival rate and a significant proportion of patients retaining their bladder 7.
- Immunotherapeutic strategies, including intravesical Bacillus Calmette-Guérin (BCG) and immune checkpoint inhibitors, have revolutionized the management of bladder cancer, offering promising response rates and improving treatment efficacy 3.
- The extent to which complete TURBT improves response to chemotherapy is still unclear, but it is associated with improved survival and oncologic outcomes in patients with muscle-invasive bladder cancer 4, 5.
Treatment Options
- Neoadjuvant chemotherapy followed by radical cystectomy is a common treatment approach for muscle-invasive bladder cancer, but it can be associated with significant morbidity and impact on quality of life 3, 4.
- Bladder-preserving therapies, including TURBT and immunotherapy, are being increasingly explored as alternative treatment options for patients with muscle-invasive bladder cancer 3, 6.
- Combination regimens integrating radiotherapy, chemotherapy, and immunotherapy can enhance treatment efficacy and exploit mechanisms such as immunogenic cell death and antigen release to further augment antitumor immune responses 3.
- The choice of treatment approach depends on various factors, including the stage and grade of the tumor, patient comorbidities, and patient preferences 4, 7.
Predictive Factors
- Complete TURBT prior to neoadjuvant chemotherapy is a significant predictor of improved survival and oncologic outcomes in patients with muscle-invasive bladder cancer 4, 5.
- T2 stage and complete histologic resection in initial TURB are predictive of best outcome in patients with TCC 7.
- The presence of variant histology and hydronephrosis can impact treatment outcomes and prognosis in patients with muscle-invasive bladder cancer 4.