Management of clinical stage T3/T4 bladder cancer: a review

Bladder cancer is a common malignancy in the United States and while the majority are non-muscle invasive at diagnosis, those with muscle-invasive and locally advanced disease can be challenging to manage. In addition, the prognosis is poorer in this group with high rates of recurrence following treatment. Clinical trials and advances in systemic therapy have helped to improve outcomes for these patients. Articles were chosen for inclusion based on expert knowledge of the literature and PubMed literature searches for the relevant areas, with a focus on clinical trials. Appropriate articles were selected for inclusion by reviewing article titles, abstracts and full texts. The standard of care for treatment of muscle invasive bladder cancer involves neoadjuvant chemotherapy followed by radical cystectomy. The NIAGARA trial recently changed the standard of care to include immunotherapy both in the neoadjuvant and adjuvant settings. Multiple clinical trials have assessed the potential benefit of adjuvant immunotherapy in patients with high-risk disease after radical cystectomy, leading to the approval of nivolumab in this setting. Improvements in staging and surveillance of these patients are necessary. The use of circulating tumor DNA and advances in imaging have also shown promise in prognostication and detection and monitoring of recurrence. Locally advanced bladder cancer is a challenging condition to manage, and while advances have been made in systemic therapy and biomarkers such as circulating tumor DNA, further investigation is needed to continue to improve outcomes for this group of patients.