Bladder-Sparing Strategies for MIBC: Insights from Professor Ming Cao at ESMO Asia2024

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“Bladder-Sparing Strategies for MIBC: Insights from Professor Ming Cao at ESMO Asia2024.

Professor Ming Cao from Renji Hospital shared groundbreaking research on combining local surgery and chemoradiotherapy for bladder preservation in muscle-invasive bladder cancer patients.

As the demand for bladder-sparing approaches grows, these findings pave the way for innovative, patient-centered solutions.

Editor’s Note：Radical cystectomy remains the standard treatment for muscle-invasive bladder cancer (MIBC), but many patients express a strong desire to preserve their bladder. To address this, various bladder-sparing strategies have been explored, including transurethral resection of bladder tumor (TURBT), partial cystectomy (PC), chemotherapy, radiotherapy, and surveillance.

At the recent ESMO Asia Annual Meeting, Professor Ming Cao from Renji Hospital, Shanghai Jiao Tong University School of Medicine, presented his research on bladder preservation through postoperative adjuvant therapy for MIBC. Urology Frontier had the opportunity to discuss his findings with him on-site.

Urology Frontier: The TMT protocol (maximized TURBT combined with chemotherapy and radiotherapy) is the most evidence-based bladder-sparing approach. For MIBC patients, why is bladder preservation so important? Are there other effective strategies for bladder preservation?

Professor Ming Cao: Bladder preservation has long been a top priority for both patients and urologists in bladder cancer treatment. This is because radical cystectomy not only causes significant physical trauma but also profoundly impacts patients’ quality of life. Many patients struggle to adapt to the drastic lifestyle changes after surgery.

Furthermore, radical cystectomy alone does not guarantee optimal outcomes, as a significant proportion of patients still experience tumor metastasis within a short period post-surgery. Balancing effective tumor control with maintaining a reasonable quality of life has become an urgent challenge.

Over the past few decades, urologists have explored various treatment options, including TMT. The research cohort presented by our team at the ESMO Asia conference represents one such effective alternative. Extensive retrospective data suggest that TMT and similar protocols can partially replace radical surgery. In essence, every treatment decision revolves around the question of ‘less or more.

‘With the growing variety of therapeutic drugs and the decreasing reliance on highly invasive approaches, the focus has shifted to identifying optimal multidisciplinary treatment strategies in this era of rapid pharmaceutical advancements.

Currently, no unified standard treatment exists. However, I am confident that with the advent of more effective drugs, we will see the emergence of multiple viable bladder-sparing options. Determining the best approach, however, will require more time and data for validation.

Urology Frontier: Your team has explored bladder-sparing strategies involving postoperative adjuvant therapy for MIBC. Could you share the efficacy and safety results of combining immunotherapy with chemotherapy?

Professor Ming Cao: The greatest value of our research lies not in evaluating the combined effects of immunotherapy and chemotherapy but in highlighting the role of surgery in bladder-sparing treatment. Specifically, we explored more localized surgical approaches, optimized existing drug regimens, and reduced the radiotherapy component of TMT protocols.

During the initial stages of our study, we anticipated that a significant number of bladder cancer patients would be eligible for surgery; however, this expectation was not fully met. Nonetheless, some patients achieved satisfactory outcomes through localized surgical approaches.

While muscle-invasive patients are traditionally considered candidates for radical cystectomy, our research demonstrated that a subset of these patients could achieve complete tumor resection through limited surgery. When combined with postoperative adjuvant therapy using immunotherapy and chemotherapy, this approach effectively controlled tumor recurrence.

At the conference, international experts praised our study for its innovative design and promising results, which open the door for further exploration. Beyond incorporating immunotherapy into chemotherapy-based regimens, we are also considering other options, such as targeted therapies and ADCs (antibody-drug conjugates).

In bladder-sparing treatment strategies, we surgeons believe that the role of surgery should be further emphasized. By prioritizing localized surgical approaches, we can reduce the need for radical cystectomy. This, in essence, is the core value of our study.

Urology Frontier: For patients who experience tumor recurrence after bladder-sparing treatment, what follow-up strategies should be considered?

Professor Ming Cao: Bladder-sparing treatment has been widely studied, and there is general consensus that post-recurrence management should be tailored to the specific circumstances of the recurrence.

For superficial bladder cancer or low-grade tumors that recur, bladder-sparing strategies may still be viable. However, for high-risk factors, such as high-grade invasive tumors, salvage radical surgery should be considered. It’s worth noting that, in certain cases, such surgeries can become highly complex.

For instance, in the TMT protocol, patients who have undergone definitive radiotherapy often require a washout period before radical surgery can be performed. This is because severe tissue edema typically occurs shortly after radiotherapy, limiting its application as a complete substitute for radical cystectomy.

Urology Frontier: Multidisciplinary approaches are often emphasized in bladder-sparing treatment. What value do they bring?

Professor Ming Cao: In the past, treatment decisions were relatively straightforward, involving simpler drug and radiotherapy protocols that could be determined through brief discussions. However, with the growing complexity of treatment options—spanning advanced drug therapies, radiotherapy technologies, and interventional techniques—individual assessments by a single specialist may lack balance. This makes comprehensive multidisciplinary discussions increasingly essential.

Modern clinical practice emphasizes the concept of full-cycle management, where experts from various specialties collaborate at different stages of a disease to ensure optimal patient care and decision-making. This cross-disciplinary approach fosters more comprehensive and personalized treatment plans, leading to improved outcomes and enhanced quality of life for patients.

In my view, conducting multidisciplinary discussions at key points in the treatment journey or when combining different therapeutic approaches is a crucial aspect of current clinical practice.

Urology Frontier: Which topics at the conference caught your attention, and what changes do you foresee in future diagnostics and treatments?

Professor Ming Cao: I remain particularly focused on developments in bladder cancer diagnostics and treatment. Our team not only works to optimize and innovate bladder-sparing strategies but also investigates effective measures to address tumor recurrence following treatment failure.

Additionally, we are actively researching ways to implement robust monitoring during bladder-sparing therapy and have made notable progress in this area. Looking ahead five to ten years, we expect breakthroughs in bladder cancer treatment driven by advancements in monitoring technologies, more refined therapies, and closer multidisciplinary collaboration. This progress will likely result in a significant reduction in the number of patients requiring radical cystectomy, with this trend accelerating at an unprecedented rate.Bottom of Form

Professor Ming Cao, Deputy Chief Physician, MD Deputy Director, Bladder Tumor Diagnosis and Treatment Center, Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine

• Standing Member of the Medical International Exchange Promotion Committee, China Association of Medical Education
• Member of the Digital and Artificial Intelligence Group, Urology Physicians Branch, Chinese Medical Doctor Association
• Secretary and Inspection Expert, Shanghai Urological Quality Control Center
• Member of the Smart Healthcare and Artificial Intelligence Committee, Shanghai Society of Integrative Medicine
• Adjunct Professor, Renji-Ottawa Joint Medical School, University of Ottawa
• Teaching Supervisor, Clinical Medical School, Renji Hospital, Shanghai Jiao Tong University School of Medicine

Professor Cao has led and participated in numerous national and provincial-level research projects. Notably, his research on molecular diagnostics in bladder cancer was completed in 2020 and rated as an Outstanding Project by the Shanghai Municipal Education Commission. He has published dozens of papers, including in leading journals such as European Urology and Cancer Communications. As the first author or corresponding author, he has contributed to SCI papers with a total impact factor exceeding 100, with the highest single-paper IF reaching 24. He also holds one invention patent.”