Content area
Full Text
In this issue of ONCOLOGY, Kamat and Mathew provide an excellent overview of the current status and future imperatives of bladder cancer treatment and research. As the authors highlight, and as other experts have recently written, [1] a paradigm shift is long overdue. The basic management of bladder tumors has remained essentially unchanged for over 50 years, and despite its importance- on account of the incidence, prognosis and cost of the disease- bladder cancer research remains significantly underfunded. [2] Every aspect of our perception and management of this disease requires change; abandoning the use of the term "superficial" bladder cancer is just the first step [3]- the term is both inaccurate and implies a lack of importance that is completely wrong. In particular, given the very high costs to healthcare systems from long-term surveillance and treatment of the disease, [4] it is particularly surprising that there has not been more emphasis on the disease from health policy makers and pharmaceutical companies.
Demographically, the industrializing nations will contribute to a significant rise in the global incidence of bladder urothelial carcinoma, [5] with particularly large numbers likely in China given the rapid improvement in the standard of living and the high prevalence of smoking. However, despite the falling incidence in developed nations, specific challenges remain, chiefly stemming from the aging population and increased life expectancy. Within two large cohorts separated by 15 years (1991-92 and 2005-10), we have recently demonstrated an increase in age at presentation of 4 years, with an increase from 13% to 24% in the proportion of patients over 80 years. [6] Technically, treatment in this aging cohort may become more feasible with the advances in minimally invasive and robot-assisted surgery. There is also significant scope for improving the primary surgery that we offer to all patients: transurethral resection. New instruments may allow us to move away from the "incise and scatter" nature of existing procedures, [7] and we already know that new optical and image -enhancement technologies allow us to carry out more thorough tumor resections. [8]
In addition, a rethink of the view that cystectomy is the gold standard for invasive bladder cancer is long overdue. Comparisons of large surgical[9] and radiotherapy[10] series suggest very similar long-term survival rates, and population...