Institute of Urologic Oncology (IUO), Department of Urology, David Geffen School of Medicine, University of California, Los Angeles.
JAMA. 2020 Nov 17;324(19):1980-1991. doi: 10.1001/jama.2020.17598.
Bladder cancer is a common malignancy in women and is the fourth most common malignancy in men. Bladder cancer ranges from unaggressive and usually noninvasive tumors that recur and commit patients to long-term invasive surveillance, to aggressive and invasive tumors with high disease-specific mortality.
Advanced age, male sex, and cigarette smoking contribute to the development of bladder cancer. Bladder tumors can present with gross or microscopic hematuria, which is evaluated with cystoscopy and upper tract imaging depending on the degree of hematuria and risk of malignancy. Non-muscle-invasive tumors are treated with endoscopic resection and adjuvant intravesical therapy, depending on the risk classification. Enhanced cystoscopy includes technology used to improve the detection of tumors and can reduce the risk of recurrence. Patients with high-risk non-muscle invasive tumors that do not respond to adjuvant therapy with the standard-of-care immunotherapy, bacille Calmette-Guérin (BCG), constitute a challenging patient population to manage and many alternative therapies are being studied. For patients with muscle-invasive disease, more aggressive therapy with radical cystectomy and urinary diversion or trimodal therapy with maximal endoscopic resection, radiosensitizing chemotherapy, and radiation is warranted to curb the risk of metastasis and disease-specific mortality. Treatment of patients with advanced disease is undergoing rapid changes as immunotherapy with checkpoint inhibitors, targeted therapies, and antibody-drug conjugates have become options for certain patients with various stages of disease.
Improved understanding of the molecular biology and genetics of bladder cancer has evolved the way localized and advanced disease is diagnosed and treated. While intravesical BCG has remained the mainstay of therapy for intermediate and high-risk non-muscle-invasive bladder cancer, the therapeutic options for muscle-invasive and advanced disease has expanded to include immunotherapy with checkpoint inhibition, targeted therapies, and antibody-drug conjugates.
膀胱癌是女性常见的恶性肿瘤，也是男性第四大常见恶性肿瘤。膀胱癌的范围从侵袭性较弱且通常为非侵袭性的肿瘤，这些肿瘤会复发并使患者长期接受侵袭性监测，到侵袭性和高疾病特异性死亡率的侵袭性肿瘤。
年龄增长、男性和吸烟会导致膀胱癌的发生。膀胱癌可表现为肉眼血尿或镜下血尿，根据血尿程度和恶性肿瘤风险，采用膀胱镜检查和上尿路影像学进行评估。非肌肉浸润性肿瘤采用内镜下切除和辅助膀胱内治疗，取决于风险分类。增强膀胱镜检查包括用于提高肿瘤检测率的技术，可降低复发风险。对于标准护理免疫疗法（卡介苗）治疗后无反应的高危非肌肉浸润性肿瘤患者，构成了具有挑战性的管理人群，许多替代疗法正在研究中。对于肌层浸润性疾病患者，采用根治性膀胱切除术和尿流改道术或最大限度的内镜下切除、放射增敏化疗和放疗的三联疗法，以遏制转移和疾病特异性死亡率的风险是必要的。随着免疫检查点抑制剂、靶向治疗和抗体药物偶联物等免疫疗法成为某些不同疾病阶段患者的选择，晚期疾病的治疗正在迅速发生变化。
对膀胱癌的分子生物学和遗传学的深入了解已经改变了局部和晚期疾病的诊断和治疗方式。虽然膀胱内卡介苗仍然是中高危非肌肉浸润性膀胱癌的主要治疗方法，但肌肉浸润性和晚期疾病的治疗选择已扩大到包括免疫检查点抑制、靶向治疗和抗体药物偶联物的免疫疗法。
