Expert Reviews Alternative Treatment Options in Muscle-Invasive Bladder Cancer

Shilpa Gupta, MD, shares the current standard of care for muscle-invasive bladder cancer and highlights other options that may be suitable for some patients.

Neoadjuvant cisplatin-based chemotherapy and radical cystectomy is the current standard of care for patients with muscle-invasive bladder cancer, although other options could be a good choice for certain patients, according to Shilpa Gupta, MD.

Gupta, a genitourinary oncologist from Case Comprehensive Cancer Center, spoke with CancerNetwork® during the 2023 Genitourinary Cancers Symposium about the importance of bladder preservation in younger patients. Although transurethral resection of bladder tumor (TURBT), concurrent chemotherapy, and radiation was once a regimen reserved for older patients who weren’t good candidates for surgery, the regimen should also be considered in younger patients.

She also discussed the best regimen for patients who are cisplatin ineligible, including unfit patients. Importantly, she emphasized that surgery may not be the best option for unfit patients who have a poor physical performance status.


The current standard [of care] for muscle-invasive bladder cancer is neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy. Since our patient population has a median age of 71 [years old], many patients may not be fit for cystectomy.

If they have tumors that are smaller, there is no hydronephrosis, and no widespread carcinoma in-situ, tri-modality therapy with maximal TURBT, concurrent chemotherapy, and radiation is another valid option. In the past, this used to be reserved for patients who are unfit for surgery or are older and not going to tolerate the surgery well but nowadays, a lot of younger patients are also interested in preserving their bladders.

They ask us about this option up front. For patients who are not eligible to receive cisplatin-based chemotherapy due to chronic kidney disease, hearing loss, heart failure, neuropathy, or just poor physical performance status for them, ideally, the up-front cystectomy is the option. [However], if they are overall in poor shape, then again, surgery may not be the best option.

It all depends on the patient's performance status.

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