Selective multimodal bladder-sparing therapy for muscle-invasive bladder cancer: the present and the future

ABSTRACTIntroduction Despite the lack of level 1 evidence, selective bladder-sparing therapy using trimodal therapy is currently recommended by guidelines as a standard of care in patients with non-metastatic, muscle-invasive bladder cancer who are eligible for the treatment.Areas covered This article reviews major studies of selective, bladder-sparing therapy utilizing multiple modalities for muscle-invasive bladder cancer and those comparing the oncological outcomes between bladder-sparing therapy and radical cystectomy. Also discussed are predictive biomarkers potentially capable of guiding treatment decisions by patients with muscle-invasive bladder cancer and a novel strategy for boosting the antitumor immune response in bladder-sparing therapy. PubMed databases were searched for records of 30 June 2023 or earlier.Expert opinion Selective, bladder-sparing therapy appears to be underutilized at present. To promote its use, measures should be taken to facilitate the referral of eligible patients to specialist centers and broaden the number of facilities providing the therapy. Recent studies have suggested a prognostic benefit of radiotherapy for the primary lesion in patients with metastatic bladder cancer. Given that irradiation can induce the abscopal effect, particularly in combination with immune checkpoint inhibitors, demand for bladder-sparing therapies may increase in the context of treatments for metastases.KEYWORDS: Chemoradiotherapyimmunotherapymuscle-invasive bladder cancerorgan preservationBiomarker Article highlights Selective bladder-sparing therapy with trimodal therapy is one of the standard treatments for patients fit for a radical cystectomy and is currently recommended by guidelines for eligible patients with muscle-invasive bladder cancerSelective bladder-sparing therapy and the radical cystectomy should not be considered mutually exclusive; some patients with low-risk, muscle-invasive bladder cancer can be cured with a minimally invasive strategy while preserving their quality of life.The success of bladder-sparing therapy lies in selecting appropriate candidates and providing curative modalities based on multidisciplinary, shared decision-making.Several biomarkers may help physicians choose between bladder-sparing therapy or a radical cystectomy in the context of multidisciplinary, shared decision-making.Given that radiotherapy can induce an antitumor immune response, combining it with immunotherapy may improve the oncological outcomes of bladder-sparing therapy. Clinical trials are currently being performed to study this topic.Declaration of interestThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.Reviewer disclosuresPeer reviewers on this manuscript have no relevant financial or other relationships to disclose.Additional informationFundingThis paper received no funding.