Industry Insight

How can the combined power of multidisciplinary teams and precision medicine be harnessed for people living with bladder cancer?

Eva Compérat at the University of Vienna, Austria.

In the last 250 years, we’ve witnessed incredible milestones in cancer research, discovery and treatment.1 We now know there are over 200 different types of cancer and a one-size-fits all treatment doesn’t exist.2

Bladder cancer is a prime example – with a diagnosis that relies mainly on cystoscopy, it can be one of the most difficult cancers to diagnose and treat.3 More than half a million people were diagnosed with bladder cancer worldwide in 2022 – nearly 225,000 of which were in Europe.3,4 Two decades since inception, the multidisciplinary team (MDT) is widely considered the gold standard of cancer care delivery.5 In the same two decades, there has also been the advancement of precision medicine (PM) for cancer.6 How do clinicians and experts harness this combined power for those with bladder cancer?

It’s essential for pathologists to work with MDTs and PM across bladder cancer

The ideal MDT draws expertise from a range of specialists for diagnosis, referral and treatment. Pathologists treating bladder cancer play a crucial role when presenting findings to the MDT.7

A pathologist may not always be able to detect disease, especially if the tumour has not invaded tissue. Another challenge is the diversity of subtypes encountered, as well as sample sizes. Clinicians regularly want to know about tissues markers like programmed death-ligand 1 (PDL1) or CDKN2A but experts agree you need a gene-based test.7

Gene-based testing, like fibroblast growth factor receptor (FGFR) testing, is critical if this type of tumour is suspected. As such, there is a need to be testing at the genetic level and not the tissue level.7 Bladder cancer is characterised by significant molecular and tissue heterogeneity.8 There are numerous promising biomarkers in both neoadjuvant and metastatic settings being tested, but these remain investigational (molecular subtypes of urothelial carcinoma [UC], DNA damage response [DDR] gene alterations, and alterations of PIK3CA and genes encoding the ErbB family of receptor tyrosine kinases [RTKs]).8

The MDT is particularly useful in PM, especially for bladder cancer with a complex genetic disease make up.9 PM experts – such as molecular pathologists or molecular geneticists – can help interpret genetic data and assist doctors with treatment plans, but are not often part of the normal bladder cancer MDT. The ideal bladder cancer MDT should combine aspects such as the main complaint, pathology, biochemical indexes, radiological images and more.

The MDT process needs to be organised and consistent to serve patients

All silos affecting the MDT need to be removed so that all relevant specialists have a seat at the table. For complex patients on secondor third-line therapies, we have molecular tumour boards (MTBs). The meeting happens every two weeks where we look to find an actionable target through next-generation sequencing (NGS) testing and there’s not always time for preparation. We need to focus on avenues to improve and streamline handovers between stakeholders to avoid losing patients during the PM journey.

What does the future of the MDT and PM combination for bladder cancer look like?

Three things are essential for the future if we are to transform care using the MDT and PM:

• Pathologists are a crucial part of the MDT for bladder cancer and need to work hand in hand with surgical, surgical pathology and PM specialists
• Gene testing is key
• Careful and consistent orchestration of the MDT team meetings are needed.

As we now champion MDT and PM in practice, we lay the foundation for long-term results in the future. Pioneers of PM also need to publish to make a global impact.

As we gather long-term results and patient successes, the results will speak for themselves and we will see impressive changes to match or exceed the last 250 years of cancer research.

References

1. Visit: cancer.gov/research/progress/250years-milestones. Accessed August 2024
2. Visit: nhs.uk/conditions/cancer/
3. Visit: iarc.who.int/cancer-type/bladdercancer/
4. Visit: gco.iarc.fr/en
5. Winters DA et al (2021), ‘The cancer multidisciplinary team meeting: in need of change? History, challenges and future perspectives’, BJU Int, 128(3), pp271-279
6. The Lancet (2021), ‘20 years of precision medicine in oncology’, Lancet, 397(10287), p1781
7. Expressed by author in conversation
8. Guercio BJ et al (2021), ‘Developing Precision Medicine for Bladder Cancer’, Hematol Oncol Clin North Am, 35(3), pp633-653
9. Visit: onlinelibrary.wiley.com/doi/10.1002/ctd2.217