Expert Interview of Dr Carballo: The Role of Radiotherapy for MIBC Patients

Natalia Carballo, MD
Sanitas Hospitals/Atrys Health
Madrid, Spain

The therapeutic landscape for urothelial cancer (UC) has undergone significant transformation in recent years, with the addition of PD-1/PD-L1 targeting immune checkpoint inhibitors (ICI) and novel targeted therapies and antibody-drug conjugates (ADCs) adding to the complexity of treatment options available for patients throughout the course of their disease. The optimal sequencing of treatments depends on an understanding of the relevance of different pathological subtypes of the disease and of the latest clinical evidence and guidelines that support the use of different therapies.

By this expert interview, you will receive a detailed grounding of the disease process and management from diagnosis through to salvage treatments of advanced disease. The course will enable clinicians who are involved in the management of patients with urothelial cancer to integrate the latest advances and use of novel therapies for advanced urothelial cancer into safe and effective patient care. 

Transcript

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Bladder-sparing trimodality treatment (TMT) is an accepted alternative to radical cystectomy (RC) for selected patients with who are unfit for or prefer to avoid cystectomy. How should candidates for bladder preservation be selected? The most important point about this question is selection. So we require, first of all, that the patient asks for this preservation. So first is the patient's desire. And afterwards we need to look at many situations and different circumstances. First, no multisite or multicentric tumors. No more than six centimeters in the bigger size. Also that before chemoradiation therapy, the patient should preserve good renal function and also good bladder function. And normally, if the patient is fit, age is not so important. We can also consider older patients for this preservation with chemoradiation therapy. But the key point is to have good renal function and good bladder function, and also to meet other requirements in terms of size and the absence of multicentric bladder tumor. Bladder-sparing approaches are under investigation in clinical trials, aiming to improve survival outcomes and quality of life. What is the optimal treatment strategy for bladder preservation from your perspective? In my perspective, there are three aspects that we need to consider, and they are all very important. First, to be in contact with the colleagues that will be involved in this procedure: medical oncologists and urologists. Second, to select better candidate possible to this procedure. And for me, the third and probably the most important, also with the same importance as the other two, is to have good technical equipment in terms of radiation oncology. With these three and with the collaboration with the other disciplines, and also with a good technology, we can deliver very safe treatments with little toxicity to the patients, which is often one of the concerns of bladder preservation. What are the potential additional values and clinical applications of radiotherapy in the management of urothelial carcinomas? What is the current status of development in adjuvant radiotherapy and chemoradiotherapy? The role of radiation therapy is evolving as the clinical trials are publishing the finding that probably immunotherapy plays a major role. But still, radiation therapy in combination with chemotherapy has level 1 evidence, because of the phase III trial that we have with long-term follow-up. So obviously, in the adjuvant setting, for those patients who, after cystectomy, have a poor T4 with positive lymph nodes or positive margins, radiotherapy still plays a role. And for the concomitant chemoradiation therapy, we need to redefine which is the future of this combination, but it still has a potential because we have very important level 1 evidence saying that it is equal to cystectomy in selected patients. So probably now we have a role for muscle-invasive bladder cancer (MIBC). But we need to redefine what is the role of radiation therapy. Especially in the future, knowing that we have results saying that probably with those who are very good responders to chemo and immunotherapy, possibly we don't need to require local treatments. But again, now radiation and chemotherapy have level 1 evidence. So we need to go far with those clinical trials that are now under study and see what is the future role for these patients, especially with clinical response.