From the Guidelines
Radical cystectomy combined with immunotherapy can be a viable option for invasive bladder cancer patients who cannot undergo chemotherapy, as evidenced by recent guidelines and studies 1. This approach may be considered for patients who have medical contraindications to chemotherapy, such as poor kidney function, heart disease, or other comorbidities that make chemotherapy too risky. The standard immunotherapy agents used include checkpoint inhibitors like pembrolizumab (Keytruda), atezolizumab (Tecentriq), nivolumab (Opdivo), or avelumab (Bavencio), typically administered intravenously every 2-3 weeks.
Key Considerations
- These medications work by helping the immune system recognize and attack cancer cells by blocking proteins that prevent T-cells from identifying and destroying the cancer.
- Before proceeding with this treatment plan, patients should undergo comprehensive staging with CT scans and possibly PET imaging to ensure the cancer hasn't spread beyond the bladder.
- It's essential to understand that while this approach can be effective, the traditional gold standard for muscle-invasive bladder cancer remains neoadjuvant (pre-surgery) cisplatin-based chemotherapy followed by radical cystectomy, as this combination has shown the best survival outcomes in clinical trials 1.
- The decision should be made after thorough discussion with a multidisciplinary team including urologists and oncologists who can evaluate individual circumstances.
Recent Guidelines and Studies
- A recent guideline published in 2024 1 supports the use of immunotherapy in the treatment of non-metastatic muscle-invasive bladder cancer, highlighting the need for further studies to demonstrate the oncologic efficacy and potential for improved clinical outcomes.
- Another study published in 2017 1 provides a consensus statement for the use of immunotherapy in patients with bladder cancer, emphasizing the importance of patient selection, toxicity management, and combination and sequencing of therapies.
- The NCCN guidelines insights published in 2016 1 also discuss the advancement of treatment options for bladder cancer, including immunotherapy and checkpoint inhibitors, and highlight the need for universal implementation of these changes in clinical practice to improve patient outcomes.
From the Research
Treatment Options for Invasive Bladder Cancer
- Radical cystectomy (bladder removal) is a standard treatment for patients with invasive bladder cancer, as it provides the best survival rates with the lowest local recurrence rates 2, 3, 4.
- Immunotherapy has shown promising results in the treatment of muscle-invasive bladder cancer, and its use in combination with radical cystectomy is being explored 5, 6.
- Neoadjuvant chemotherapy (NACT) is currently the standard recommended treatment for muscle-invasive bladder cancer, but the role of adjuvant therapy and immunotherapy is still being debated 6.
Radical Cystectomy and Immunotherapy without Chemotherapy
- There is evidence to suggest that radical cystectomy and immunotherapy can be an effective treatment option for invasive bladder cancer, even without chemotherapy 5.
- A case study reported a patient with muscle-invasive bladder cancer who responded well to pembrolizumab (an immune checkpoint inhibitor) before undergoing radical cystectomy, with no recurrence after 18 months 5.
- However, more research is needed to fully understand the efficacy and safety of this treatment approach, and to determine which patients may benefit from it 2, 3, 6, 4.
Key Considerations
- The decision to use radical cystectomy and immunotherapy without chemotherapy should be made on a case-by-case basis, taking into account the individual patient's disease characteristics, overall health, and treatment goals 6.
- Further studies are needed to explore the potential benefits and risks of this treatment approach, and to establish clear guidelines for its use in clinical practice 2, 5, 3, 6, 4.