Treatment of muscle-invasive bladder cancer

Bladder cancer incidence places the Central European region among the leading areas worldwide. In recent years, however, a slow improvement has been observed in mortality statistics, attributable to the reduction in smoking, advances in diagnostics, and the availability of modern treatment options. Nearly a decade ago, with the introduction of immunotherapy, it became possible to prolong progression-free survival even in patients with metastatic disease who were ineligible for platinum-based chemotherapy, although the improvement in overall survival remained modest. The first significant survival benefit entered daily clinical practice with the use of maintenance immunotherapy following chemotherapy. In the past few years, however, additional novel therapeutic strategies have emerged that fundamentally change current clinical practice, both in the metastatic and perioperative settings. Accordingly, international guidelines have been revised: enfortumab vedotin combined with pembrolizumab, as well as nivolumab in combination with chemotherapy (gemcitabine–cisplatin), have become new first-line treatment options. In localized disease, chemo-immunotherapy with durvalumab plus gemcitabine and cisplatin/carboplatin has yielded promising results, and this combination has been incorporated into the most recent NCCN guidelines. The aim of this article is to review the current systemic treatment options for muscle-invasive bladder cancer, based on the latest phase 3 trial results, and to present subgroup analyses and biomarker data, in order to assist clinicians in developing the “optimal treatment strategy” in everyday practice.