Identifying high-risk patients: Key for optimal BCa management

07 May 2018

For many physicians bladder cancer management is replete with challenges and pitfalls, and with the recent developments in drug development and molecular classifications, specialists encounter dilemmas that prompt a critical look at both current practices and novel treatment options.   

“Bladder cancer (BCa) comprises different aspects that deserve attention. At the non-muscle invasive, low and intermediate risk types, BCa is a costly disease mainly due to its recurrent nature and the consequent life-long follow-up. Having said that, we should focus on risk-adapted strategies, overcome (the limited) outcomes of current endovesical therapies, find new agents that could help us prevent recurrence, and identify new markers that could serve as key aspects for better monitoring, diagnosis, follow-up and individualised therapy,” said Prof. Maria Ribal (ES), speaker and faculty member at the forthcoming  EAU Update on Bladder Cancer (BCa18) to be held on 8 and 9 June in Munich, Germany.

Ribal, urology professor the University Hospital Clinic of Barcelona, stressed the same is true for high-risk non-muscle invasive bladder disease, which also poses unique challenges to physicians looking for optimal management.

“Particularly  with the development of future prognostic markers— which is proving even more important since this enable us to identify those patients that need radical therapy upfront. In muscle invasive disease, it is significant to point out that monotherapy probably cannot be an option for advanced disease,” she said. “We should be aware that a multidisciplinary approach combining surgery and systemic therapy is the way to achieve better survival in this subset of patients.”

These aforementioned decision-making issues and management dilemmas are among the key topics that BCa18 will tackle during the two-day meeting. Part of the EAU onco—urology series, BCa18 is an interactive and compact educational event, with expert update lectures preceding a round of break-out group discussions.

Improving management

There are many areas in BCa management that require a more individualized approach, according to Ribal, adding that this option has now become more accessible due to new research developments.

“High-risk NMIBC remains a challenging disease to manage, with endovesical therapies and TURB still considered the main tools for management. But it is necessary to recognize that a non-depreciable percentage of patients will develop a muscle-invasive and, in these cases, the mortality is higher than in the novo muscle invasive disease. A  clear identification of those at risk is mandatory, even before starting any endovesical therapy or offering an early cystectomy, which could improve survival in this subset of patients,” she pointed out.

Moreover, in the absence of reliable markers, certain morphological aspects such as tumour burden, depth of micro-invasion and associate carcinoma in-situ (CIS) would aid physicians to select those patients that should be offered an early cystectomy, Ribal added.

Ribal, who will speak in Munich on palliative cystectomy, its indications and patient selection, further noted the impact of recent changes in the molecular classification of bladder cancer.

“The molecular classification of muscle invasive bladder cancer has been recently released, demonstrating correlation with prognosis and chemo-sensitivity. Molecular markers have been incorporated successfully in the management of other malignancies, and probably we do really need to incorporate them into bladder cancer management,” she said.

Individualised therapies

Regarding emerging therapeutic options such as immunotherapy, Ribal reiterated that patient characteristics determine which cases are suitable.

“It would be crucial to define which patients could be given chemotherapy and which ones could be better managed by immunomodulation.  Furthermore, it is necessary to know the impact of this classification on non-invasive disease and to find the correct platform for the analysis that helps determine an effective way to achieve clinical implementation,” she explained.

Awareness of bladder disease remains relatively low and the consequences are seen in both the medical community and the general public as well.

“Bladder cancer is not seen as frequently as prostate cancer and, perhaps, because of this it has not drawn much interest for quite some time, nor has it attracted the same level of funding compared with other malignancies. It is time to change this,” Ribal said. “We should increase the awareness about the disease, particularly  how a single decision at any stage of the disease could have a big impact on patient survival and their quality of life.”

With a focused update meeting such as BCa18 where the emphasis is to boost knowledge, refine skills, and improve management decisions, Ribal said participants can expect to gain key insights on best practices and prospective treatment options.

Ribal: “At BCa18, we would stress all the key points previously mentioned and give a comprehensive overview of the disease to help us improve the management of bladder cancer patients.”

CME-accredited, BCa18 benefits from the EAU’s collaboration with specialised affiliate offices, related medical disciplines and the European School of Urology, enabling the organisers to harness the expertise of opinion leaders and specialists from various centres and institutions across Europe.

Don’t miss this year’s most important Bladder Cancer meeting. Register now!

Article by Joel Vega