FIG. 7:  I would suggest that bladder cancer survival is not improving because of three factors:

• Disease biology. We know that as a smoking-related cancer or an occupational carcinogen-caused cancer, bladder cancers have high mutation rates, a high mutation burden, and they are aggressive, so they are often resistant to treatment.^[9] Multimodal cisplatin-based chemotherapy is probably best, but it only improves survival outcomes marginally, and we know that resistance to chemotherapy or radiotherapy is relatively high.  Recurrence rates are high, as are progression rates following initial treatment.  So the biology is against us, but that will be difficult to overcome without new treatments. 
• Need for new treatments. After many years there are now some new treatments on the horizon with immune checkpoint inhibitors.  There have been from some promising results with programmed cell death protein-1 (PD-1) inhibitors and programmed cell death ligand-1 (PD-L1) inhibitors,^[10] with perhaps 20% of patients getting a good and durable response to these immune therapies in early clinical studies.  However this still represents only a minority of patients; we are waiting for treatments that will improve survival for the majority of patients. More importantly, we are waiting for results from large Phase 3 prospective studies to know whether the promise of PD-1 or PD-L1 inhibitors will bear fruit. 
• Suboptimal application of current care. The current state of treatments today is not optimal, and near-term outcomes can probably be improved simply by better preparation and application of current care.