While radical cystectomy (RC) remains the predominant curative-intent treatment in patients with nonmetastatic muscle-invasive bladder cancer (MIBC), bladder-sparing protocols incorporating transurethral resection of visible tumor followed by chemoradiation have amassed a body of evidence supporting their role as an alternative to extirpative surgery in carefully selected patients. As such, bladder-sparing approaches are now included as alternatives to RC in several contemporary guideline statements.

At the 2023 American Society of Clinical Oncology meeting in Chicago, we presented a patient-centered panel discussion regarding the optimal selection of patients for bladder-sparing protocols, with the objective of delving into the nuances of counseling, patient selection, and optimizing protocols for chemoradiation. The panel began with a presentation of a case of a 60-year-old otherwise healthy male schoolteacher, who was diagnosed with a 4 cm polypoid mass emanating from the left bladder wall with no involvement of the upper tracts and no radiographic evidence of metastatic disease (cT2N0M0). Following a visually complete transurethral resection, his final pathology was a high grade papillary and solid urothelial carcinoma with invasion of the muscularis propria, lymphovascular invasion, no associated carcinoma in situ. We started our discussion by hearing from Melanie Costin, a bladder cancer survivor and patient advocate at Fight Bladder Cancer, who provided critical insights from the patient perspective regarding the initial experience of receiving a diagnosis of bladder cancer. She provided the audience with actionable recommendations for how to best deliver the diagnosis of bladder cancer in a manner that patients will be able to receive and comprehend, as well as some key resources to help facilitate this discussion. She underscored the critical importance of thoughtful communication at the moment a patient receives a diagnosis of bladder cancer and offered concrete recommendations for the audience to take home regarding how to help patients receive their diagnosis and become educated on the options that may be available to them for their treatment.

We then discussed key aspects of decision-making around selecting ideal candidates for trimodality therapy (TMT). Specifically, we highlighted the complexity of the analysis that providers undertake when counseling a patient regarding their fitness for treatment for MIBC that spans patient-comorbidity burden, frailty, and implications of different treatment options with respect to short- and long-term quality of life. With respect to identifying optimal candidates for bladder-sparing protocols, Dr Mian reviewed ideal patient selection criteria including good bladder function, diagnosed with a solitary tumor less than 7 cm in diameter in the absence of extensive carcinoma in situ, and no metastatic disease, as well as those without bilateral hydronephrosis. He emphasized the fact that individuals considering TMT should not have had prior pelvic radiation and should express commitment to follow up with the extensive posttreatment surveillance that TMT requires.

We then reviewed published contemporary comparative efficacy outcome data for patients with MIBC undergoing bladder-sparing protocols compared to RC with or without neoadjuvant chemotherapy, specifically reviewing the results of the recently published multicenter study by Zlotta and colleagues that demonstrated comparable cancer-specific and metastasis-free survival rates between propensity score–matched cohorts of patients who had received TMT vs RC.¹ The study also demonstrated comparable outcomes across institutions and a salvage cystectomy rate of 13% among the TMT cohort, with just under 5 years median follow-up. Among the participating high-volume tertiary care centers, the authors observed a 2.5% 90-day mortality rate among patients undergoing RC, which is similar to prior reports in the literature. We acknowledged the limitations of this real-world observational cohort, including the potential for selection bias and unmeasured confounding, but discussed the implications of this analysis given the lack of level 1 evidence in this arena related to the ethical and pragmatic challenges that preclude carrying out a randomized controlled trial comparing RC to TMT.

Working under the assumption of equivalent intermediate-term oncologic outcomes based on this data, in patients who are excellent candidates for TMT or RC, we then delved into the critical aspects of eliciting a patient’s priorities with respect to short- and long-term outcomes to guide the shared decision-making discussion. We emphasized the importance of helping patients to understand the short-term toxicities and risks of TMT compared to neoadjuvant chemotherapy followed by RC, both with respect to potential medical complications and side effects of therapy that could impact independence and patient function, as well as long-term toxicities. We discussed the importance of carefully providing informed consent that transparently conveys the expectations for recovery with both treatment options to navigate the decisional conflict that can confront patients.

We then addressed several of the key knowledge gaps that persist when providing bladder-sparing therapy. We reviewed current guidelines regarding the receipt of radiosensitizing chemotherapy regimens such as cisplatin, low-dose gentamicin, or 5-fluorouracil and mitomycin and then debated the rationale for and against providing neoadjuvant chemotherapy to patients pursuing bladder-sparing treatments. We also discussed the current discussion around the importance of a visually complete transurethral resection of bladder tumor prior to initiation of chemoradiation, given that many of the landmark papers demonstrating acceptable oncologic outcomes following TMT suggested improved oncologic outcomes and lower rates of requirement for RC among patients receiving a visibly complete resection.²

Finally, we addressed the components of post-TMT surveillance, including routine cystoscopy, cross-sectional imaging, and metabolic testing recommended by current guidelines. Importantly, given that up to 1 in 5 patients will develop a nonmuscle-invasive recurrence, we reviewed the fact that these patients are candidates for further intravesical induction therapies with the objective of preserving their native bladders, but also addressed the available outcome data and surgical considerations for patients who develop a muscle-invasive recurrence warranting salvage cystectomy. Relevant to the patient perspective, we commented on the financial toxicity and survivorship concerns that patients confront related to the invasiveness of the surveillance and discussed strategies to partner with patients to improve their quality of life throughout surveillance and survivorship. Ms Costin provided critical insights throughout this discussion related to the importance of supporting patients as they navigate decision-making, therapy, and posttreatment surveillance and survivorship, highlighting the mental health implications of this diagnosis and the long-term anxiety that many patients report that can persist even after years of being “cancer-free.” Important take-home points included the critical need to provide patients with ongoing support and accessible educational materials, as well as leverage patient advocacy organizations such as Fight Bladder Cancer and the Bladder Cancer Advocacy Network to optimize quality of life and facilitate patients’ access to information and community. We are grateful to the American Society of Clinical Oncology Program committee for permitting this rich multidisciplinary discussion regarding patient selection, counseling, and the nuances of bladder-sparing approaches for patients with MIBC.