Dr. Mark Soloway gave a talk on areas for improvement in bladder cancer, from his significant experience spanning a 50-year time period as a urologist-oncologist, working in many centers across the United States.
The first important area that needed improvement, according to Dr. Soloway in bladder cancer, is the dismal cure rate for locally advanced bladder cancer. In 1975 Cisplatinum was U.S. Federal Drug Administration (FDA)-approved, and Dr. Soloway began giving it to his own bladder cancer patients. 45 years later, this remains the most effective therapy for advanced urothelial cell carcinoma.
The 2nd area of improvement is in the area of bladder preservation. At that time, Dr. Soloway noted that a high percentage of patients with locally advanced bladder cancer received radiotherapy as their primary treatment modality. Dr. Soloway showed that in an animal model, combining cisplatin-based chemotherapy with radiotherapy improved outcomes significantly. In 1987, Dr. Soloway suggested that Cisplatin be considered for induction therapy before surgery. This concept was later published in a randomized phase 3 clinical trial showing the benefit of neoadjuvant chemotherapy before radical cystectomy1.
The third area of improvement was the high rate of the new or recurrent tumor (Ta/T1 bladder cancer). The high recurrence rate was suggested to be caused by constant exposure to carcinogens, lack of complete resection by urologists, and possible implantation (post-TURBT). This later lead to the recommended use of intravesical therapies, specifically the postoperative use of mitomycin C.
Dr. Soloway then focused on the treatment of low-grade Ta bladder cancer. These are the most common bladder tumors, with a high rate of subsequent tumors (30-70%), with patients rarely progressing to develop invasive tumors. The standard practice was to remove these tumors once they were discovered. However, Dr. Soloway suggested the use of cytology for the follow-up of these patients, minimizing the number of cystoscopies performed for follow-up. These patients can be safely observed, decreasing the number of times they are taken to the OR, avoiding trauma to the bladder, and reducing the morbidity of anesthesia. Therefore, for low-grade Ta bladder cancer, there are three available options:
- Active surveillance
- Office cautery
- TURBT
There is a clear benefit in avoiding the OR in these patients with avoidance of anesthesia, time-saving for the patient and for the urologist, and reduction of cost. Dr. Soloway believes there should be risk-adapted management of low-grade Ta bladder tumors. Their management should focus on minimally invasive treatment, which results in a reduction in costs without sacrificing oncological outcomes.
The last area of improvement discussed is the endoscopy and technique of TURBT. TURBT is a deceptively difficult and underappreciated operation and is the basis for bladder cancer management. There is not enough education about this procedure, with wide variability in the skill of this common operation, and little emphasis on technique, with a lack of guidelines on what constitutes adequate resection. Dr. Soloway recommends using a checklist for every TURBT procedure2. This checklist includes the following important factors:
- Review patient bladder cancer history and treatment
- Imaging review
- Discussion with anesthesia preoperatively
- Making sure the right equipment is available
- Document the procedure in detail
- Postop care and pathology review
- Formulating a management plan
- Cytology
- Deciding on the which lens to use – 12/30/70
- Assessment of grade and stage before TURBT
- Make sure the correct resection depth is reached
- Use of PDD or NBI in addition to white light cystoscopy
- Use of angled loops
- A decision on whether to use Monopolar or bipolar
- Correct Height of irrigant
- Assessment of prostatic urethra intraoperatively
Dr. Soloway ended his excellent talk summarizing key points for innovation. These include knowing yourself and what you are good at, selecting a topic and learning everything you can about it, and putting in the time and effort it requires. Lastly, it is important to remember that we all can make a difference in our field.
Presented by: Mark Soloway, MD, Chief of Urologic Oncology, Memorial Healthcare System, Hollywoodi, Florida
Written by: Hanan Goldberg, MD, MSc., Urology Department, SUNY Upstate Medical University, Syracuse, NY, USA, @GoldbergHanan at the Virtual 2020 EAU Annual Meeting #EAU20, July 17-19, 2020.
References:
1. Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant Chemotherapy plus Cystectomy Compared with Cystectomy Alone for Locally Advanced Bladder Cancer. New England Journal of Medicine 2003; 349(9): 859-66.
2. Pan D, Soloway MS. The importance of transurethral resection in managing patients with urothelial cancer in the bladder: proposal for a transurethral resection of bladder tumor checklist. European urology 2012; 61(6): 1199-203.