Noninvasive and locally invasive bladder cancer can be difficult to treat successfully. The natural history ranges from aggravating, frequent recurrences in the bladder to rapid invasion and spread. It’s now recognized that in addition to conventional urothelial cancer, there are a variety of unusual pathological variants that carry different prognoses and may respond differently to treatments.
“We are just getting to the point where we are understanding the genetic changes that occur in aggressive bladder cancers,” said Eila C. Skinner, MD, Chair and Thomas A. Stamey Research Professor of Urology at Stanford Medical School. “While bladder cancer is one of the cancers with the highest mutation rates, many of the most common genetic abnormalities, such as the tumor suppressor gene p53, do not currently have a targeted medication.”
Dr. Skinner will moderate Friday’s 30-minute presentation Tumor Board: Bladder Cancer, which begins at 10:30 am in the Esplanade Ballroom at Moscone South. The four panelists are Seth Lerner MD, FACS, professor and the Beth and Dave Swalm Chair in Urologic Oncology at Baylor College of Medicine; Yair Lotan, MD, Helen J. and Robert S. Strauss Professorship in Urology at the University of Texas Southwestern Medical Center; Neha Vapiwala, MD, associate professor of Radiation Oncology at the University of Pennsylvania Perelman School of Medicine; and Charles Ryan, MD, the Thomas Perkins Distinguished Professor of Clinical Medicine and Urology at the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco.
“We will be discussing real life cases covering some of the most vexing problems for our patients with bladder cancer, and we will take advantage of the multidisciplinary expertise on the panel,” Dr. Skinner said.
Bladder cancer is not particularly difficult to identify, she noted, but understanding the pathology, the prognosis and the range of appropriate treatment options can be complex and confusing. Part of the problem is the sheer variety of bladder cancers in phenotype and genotype. Bladder cancer pathology is in flux as experts recognize a wide variety of subtypes that appear to be much more common than previously thought. Properly characterizing the tumor is important for prognosis and treatment.
“We are going to grapple with problems that don’t have clear solutions and let the audience see how experts work their way through these complicated problems,” Dr. Skinner said. “Just understanding how to work through a complicated case and when to involve our oncology and radiation oncology colleagues can be difficult for urologists in general practice.”
Radiation can be a valuable treatment option, but not for all patients. Patient selection is one of the most important factors in achieving positive outcomes. And just as surgical and medical oncologists must sift through controversial issues in making treatment recommendations, radiation oncologists have their own set of controversies that can affect prognosis and treatment.
Personalized medicine is one of the most promising approaches in cancer treatment, but it has not become standard in bladder cancer, at least not yet. Advances in tumor genomics are identifying subgroups of invasive bladder cancers that appear to have different response to treatment. In the near future this might help predict patient response to specific treatments based on the biology of their cancer.
“Personalized medicine in bladder cancer lags behind breast cancer, for example, where there are specific genetic variants that you can test for and target with specific biologic agents,” Dr. Skinner said. “Up to now, we have not had much luck targeting growth factors or specific abnormalities in bladder cancer. However, the recent breakthroughs in immune-oncology are extremely exciting, and we will also discuss how those might be included in our treatment paradigms. Management of the more aggressive and dangerous bladder cancers is a perfect example of the importance of a multidisciplinary approach to care.”