RENAL AND UROLOGICAL PROBLEMS: Edited by Fred Saad
Bladder cancer is one of the most common solid tumors diagnosed in the world and, when it is found to be invasive, has a dismal record of survival even in the very richest countries. Given these facts it is surprising that we have had so little innovation in the last 30 years. Even though significant efforts have been made, few studies have been successfully completed in the neo-adjuvant or adjuvant setting. This has stunted our ability to demonstrate when, how, and in whom a multimodality approach is needed. Even though the studies have been difficult, many believe that there are ways at our disposal to improve the outcome of patients with bladder cancer. First, surgery needs to be as optimal as possible and must include a meticulous lymph node dissection. To achieve excellence in this type of radical surgery, volume of cases should not be underestimated. Political considerations aside, there is mounting evidence that cystectomy needs to be concentrated in centres that have high volume and in the hands of surgeons who perform them on a regular basis. Even in the best of hands, surgery will only cure less than half of the patients with invasive cancer. The article by Dr North (pp. 249–254) demonstrates that the use of chemotherapy in combination with surgery is feasible and points to better cancer control than with a purely monotherapeutic approach. Why this has not been embraced more widely remains a mystery. Even in the highest volume centers, surgery remains a challenge and with significant risks that not all patients can, or are willing to, undergo. Dr Eapan (pp. 245–248) discusses an alternative approach to radical cystectomy, which may help those delaying or avoiding urgent treatment to get treated. In properly selected patients, radiation therapy is a truly feasible approach that is often not discussed and should be. Finally, when patients arrive too late or recur, we are faced with a cure rate that is extremely low. This is largely due to the limited therapeutic options for metastatic bladder cancer. In patients able to tolerate available therapy, what to do when cancer recurs after first line therapy is still an important unmet need in oncology. Dr Sridhar (pp. 255–260) summarizes where we are and where we are going in the management of this difficult situation. One thing is absolutely certain, if patients are going to achieve any improvement in the way invasive or metastatic bladder cancer will be managed and controlled it will only be possible through the coordinated efforts of all involved including urologists, medical and radiation oncologists and pathologists.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.