Selective bladder preservation by combined modality protocol treatment: Long-term outcomes of 190 patients with invasive bladder cancer

Authors: Shipley WU, et al.
Source:UROLOGY 60: 62-68, 2002

Background

• Radical cystectomy remains the standard of care for muscle invasive bladder cancer
• Formerly, bladder preservation was only attempted in patients with small tumors with radiation alone. These attempts had poor results, with decreased local control and overall survival when compared with surgical resection
• Now, most bladder sparing therapies are with combined modality therapy, using transurethral resection of bladder tumor (TURBT) followed by concurrent chemoradiation
• This study reports on 190 patients who underwent bladder sparing therapy

Materials and Methods

• All patients had T2-4a bladder cancer
• All had a TURBT with removal of all visible tumor followed by an induction phase consisting of 40 Gy of radiation with cisplatin-based chemotherapy. Patients then underwent a repeat cystoscopy. Those who had a complete response to the induction phase went on to receive the consolidation phase, which was additional chemotherapy and radiation therapy to 64-65 Gy
• Those who did not have a complete response to induction therapy underwent immediate cystectomy so that they could still have a continent diversion
• Pretherapy workup included chest x-ray, CT scan of the abdomen of the pelvis, and bone scan.
• Starting after 1993, those patients with hydronephrosis were ineligible
• Patients were followed with exams under anesthesia every 3 months with cystoscopy and urine cytology for 2 years, at which point, follow up changed to every 6 months
• Median follow up was 7.3 years
• Results were analyzed as intent to treat for all 190 patients

Results

• Of the 190 patients, 47% were T2, with 14% having hydronephrosis
• Of the 190, 144 had a complete response to induction therapy with subsequent consolidation to 64-65 Gy
• A total of 35% underwent a cystectomy. Two-thirds did not have a complete response to induction and the other one-third had a salvage cystectomy for recurrence. No patient required cystectomy due to side effects from treatment
• Overall survival at 5 years was 54% and at 10 years was 36%
• Disease specific survival at 5 years was 63% and at 10 years was 59%
• Patients with hydronephrosis had only a 37% complete response rate to induction and therefore, few had successful bladder sparing therapy
• Of the patients who had a complete response to induction, only 16% developed a muscle invasive recurrence (the rest were superficial recurrences)

Author's Conclusions

• Combined modality therapy can achieve bladder sparing treatment for bladder cancer in many patients
• The overall survival is comparable to historical data with cystectomy
• Patient selection and careful observation is key, excluding especially those with hydronephrosis

Scientific Implications

This paper represents what should be considered standard of care for bladder sparing treatment of bladder cancer. All facets of the treatment regimen should be done carefully, ensuring a complete response in the induction phase prior to completing therapy. If a complete response is not attained, cystectomy should immediately be done, to at least attempt a continent diversion. These results are comparable to historical data with treatment by cystectomy. However, these data may be in different patient populations. Staging in this type of bladder sparing therapy is clinical, while in cystectomy data, the staging is based on pathologic data. Hence, patients staged clinically may actually be under staged, skewing the results in favor of the cystectomy patients. What is not mentioned in this paper (except to mention that no cystectomy was performed due to toxicity) is the toxicity profile of combined modality treatment. Often, patients are left with irritable bladder, the possibility of rectal complications, and a greatly reduced bladder capacity. For this reason and the fact that continent diversions can be done after cystectomy, many institutions do not routinely recommend bladder sparing treatment, though as per this paper, it can obviously be done in selected patients.