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Treatment of metastatic urothelial cancer of the bladder and urinary tract

Author
Joaquim Bellmunt, MD, PhD
Section Editor
Derek Raghavan, MD, PhD, FACP, FASCO
Deputy Editor
Michael E Ross, MD

INTRODUCTION

Bladder cancer is the most common malignancy involving the urinary system. Urothelial (transitional cell) carcinoma is the predominant histologic type in the United States and Europe, where it accounts for 90 percent of all bladder cancers. In other areas of the world, non-urothelial carcinomas are more frequent. Much less commonly, urothelial cancers can arise in the renal pelvis, ureter, or urethra. (See "Malignancies of the renal pelvis and ureter" and "Urethral cancer" and "Epidemiology and risk factors of urothelial (transitional cell) carcinoma of the bladder", section on 'Epidemiology'.)

Approximately 25 percent of patients will have muscle-invasive disease and either present with or later develop metastases. Systemic chemotherapy is the standard approach for the initial treatment of patients with inoperable locally advanced or metastatic urothelial malignancies. Although initial response rates are high, the median survival with multiagent chemotherapy is approximately 15 months [1,2]. While this is superior to the estimated six-month survival with metastatic disease prior to the development of modern chemotherapy regimens, the five-year survival rate is approximately 15 percent with contemporary regimens [2,3]. Second-line chemotherapy has had only a limited role, but checkpoint inhibitor immunotherapy offers an additional option for patients progressing after their initial systemic therapy.

The approach to systemic treatment for metastatic urothelial carcinoma arising in the renal pelvis or ureter is based upon results from trials composed primarily of patients with urothelial carcinoma of the bladder.

Systemic therapy for metastatic urothelial cancer is reviewed here. The use of neoadjuvant or adjuvant chemotherapy in conjunction with cystectomy and as part of a multimodality approach to preserve the bladder is discussed separately. (See "Neoadjuvant treatment options for muscle-invasive urothelial bladder cancer" and "Adjuvant chemotherapy for muscle invasive urothelial carcinoma of the bladder".)

PROGNOSTIC FACTORS

A number of clinical and molecular characteristics are correlated with survival. An appreciation of these prognostic factors is important for the interpretation of clinical trial results and for determining which patients may benefit from therapy. (See 'Defining medical fitness' below.)

                       

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Literature review current through: Nov 2016. | This topic last updated: Wed Nov 02 00:00:00 GMT+00:00 2016.
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