ASCO Endorses Guideline on Muscle-Invasive, Metastatic Bladder Cancer

The American Society of Clinical Oncology (ASCO) endorsed the European Association of Urology’s (EAU) treatment guideline on muscle-invasive (MIBC) and metastatic bladder cancer. Among the recommendations are standard combination neoadjuvant chemotherapy, chemoradiotherapy, and other treatments, with a focus on the need for multidisciplinary care.

“In the United States, there will be an estimated 74,000 new bladder cancer cases and 16,000 related deaths in 2015, and approximately 30% of all newly diagnosed patients present with MIBC,” wrote authors led by Matthew I. Milowsky, MD, of the University of North Carolina Lineberger Comprehensive Cancer Center in Chapel Hill. Five percent of patients present with metastatic disease, and about half of MIBC patients will develop distant metastases, “demonstrating the lethality of the disease.”

The EAU released a guideline for this malignancy in March 2015. ASCO convened an expert panel, and endorsed that guideline, with some qualifying statements, on March 21, 2016 in the Journal of Clinical Oncology.

The guideline and the ASCO endorsement stressed the need for a multidisciplinary approach to diagnosis and treatment of MIBC and metastatic bladder cancer. With regard to assessment of tumors, ASCO made several qualifying statements, including that a bladder diagram is recommended only when feasible, and pathologic reports should specify the histology along with other characteristics.

Neoadjuvant chemotherapy is recommended for all patients with T2-T4a, cN0M0 cancer; this should always be a cisplatin-based combination regimen. ASCO agreed with EAU that neoadjuvant chemotherapy is not recommended for those ineligible for cisplatin-based therapy, but added that this is not the case when the goal of treatment is downstaging surgically unresectable tumors.

Adjuvant chemotherapy-again with a cisplatin-based regimen-may be offered to those patients with pT3/4 and/or pN+ disease, if no neoadjuvant therapy has been administered. ASCO added a qualifying statement to this recommendation, noting that the adjuvant chemotherapy can be offered only in high-risk patients who hadn’t received neoadjuvant therapy.

Both organizations agreed that preoperative radiotherapy is not recommended to improve survival. However, the only EAU recommendation that ASCO specifically did not endorse was for preoperative radiotherapy for operable MIBC, which the EAU said can result in tumor downstaging after 4 to 6 weeks; ASCO authors wrote that the evidence for this does not support the recommendation.

ASCO also added a qualifying statement regarding second-line treatment for metastatic disease. EAU’s guideline recommends vinflunine in patients who progress following platinum-based combination chemotherapy, but ASCO stressed that entry into a clinical trial is preferred at this point. Alternatively, single-agent therapy with vinflunine, paclitaxel, or docetaxel could be offered.

“Overall, the panel commends the EAU on the development of its guideline on MIBC and metastatic bladder cancer and intends to disseminate it broadly to specialists and generalists in the United States who provide care for these patients,” the authors concluded.