Abstract
Bladder cancer is a heterogeneous disease that poses unique challenges to the treating clinician. It can be limited to a relatively indolent papillary tumor with low potential for progression beyond this stage to muscle-invasive disease prone to distant metastasis. The former is best treated as conservatively as possible, whereas the latter requires aggressive surgical intervention with adjuvant therapies in order to provide the best clinical outcomes. Risk stratification traditionally uses clinicopathologic features of the disease to provide prognostic information that assists in choosing the best therapy for each individual patient. For bladder cancer, this informs decisions regarding the type of intravesical therapy that is most appropriate for non-muscle-invasive disease or whether or not to administer neoadjuvant chemotherapy prior to radical cystectomy. More recently, tumor genetic sequencing data have been married to clinical outcomes data to add further sophistication and personalization. In the next generation of risk classification, we are likely to see the inclusion of molecular subtyping with specific treatment considerations based on a tumor’s mutational profile.
Highlights
Bladder cancer ranks among the most common non-cutaneous malignancies in the United States (4th for men and 11th for women) and worldwide (6th for men and 16th for women)[1,2,3]
The 2016 World Health Organization classification system for urothelial carcinoma is divided into a binary system of high and low grade, though this is mainly applicable to the lamina propria (Ta) tumors, since most (≥95%) disease ≥T1 is high grade and carcinoma in situ (CIS) is high grade by definition[5]
Upper tract evaluation is recommended as part of initial diagnostic work-up by the American Urological Association (AUA) and European Association of Urology (EAU) despite the very low likelihood of finding synchronous upper tract tumor at the time of non-muscle-invasive bladder cancer (NMIBC) diagnosis (1.5%); certain features like multifocality, trigonal location, and CIS increase the risk (7.5%)[10,11,25,26]
Summary
Bladder cancer ranks among the most common non-cutaneous malignancies in the United States (4th for men and 11th for women) and worldwide (6th for men and 16th for women)[1,2,3]. Non-muscle-invasive bladder cancer The risk tables from the European Organization for Research and Treatment of Cancer (EORTC) and scoring system from the Spanish Urological Club for Oncological Treatment (CUETO) for NMIBC classify patients into low, intermediate, or high risk for recurrence and progression to muscle invasion based on factors including grade, stage, tumor size, multifocality, variant histology, lymphovascular invasion, and prior therapy[10,11,27,28]. Radiotherapy Trimodal bladder-preserving therapy involves complete endoscopic resection of all visible tumor followed by neoadjuvant chemotherapy and definitive whole-bladder external beam radiotherapy The use of this strategy is not widespread in the United States, but prospective European cohorts have demonstrated comparable disease-specific outcomes when compared to contemporary radical cystectomy cohorts[115]. One study (EORTC 30994) was able to show an improvement in progressionfree survival; there was no statistically significant impact on overall survival[124]
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