Curative radiation therapy for very elderly bladder cancer patients with localized disease

Bladder-sparing (chemo)radiotherapy in elderly patients with muscle-invasive bladder cancer: a retrospective cohort study

BACKGROUND

Organ-sparing treatment for muscle-invasive bladder cancer by maximal transurethral removal of the tumor (TURB) followed by chemoradiation (CRT) has shown promising results in recent studies, and is therefore considered to be an acceptable alternative for the standard of radical cystectomy (RC) in selected patients. We report on outcomes in a single-center, retrospective CRT cohort in comparison to a RC and radiotherapy only (RT) cohort.

PATIENTS AND METHODS

The patient population included n = 84 CRT patients, n = 93 RC patients, and n = 95 RT patients. Primary endpoints were local control (LC) up to 2 years and overall survival (OS) up to 5 years. Cox regression was performed to determine risk factors for LC and OS in the CRT group. Acute genito-urinary (GU) and gastro-intestinal (GI) toxicity were scored with CTCAE version 4 for the RT and CRT cohort. Logistic regression was used to determine risk factors for toxicity. We followed the EQUATOR guidelines for reporting, using the STROBE checklist for observational research.

RESULTS

Baseline characteristics were different between the treatment groups with in particular worse comorbidity scores and higher age in the RT cohort. The CRT schedule was completed by 96% of the patients. LC at 2 years was 83.4% (90% CI 76.0-90.8) for CRT vs. 70.9% (62.2-79.6) for RC and 67.0% (56.8-77.2) for RT. OS at 5 years was 48.9% (38.4-59.4) for CRT vs. 46.6% (36.4-56.8) for RC, and 27.6% (19.4-35.8) for RT. High T stage was significantly associated with worse LC and OS in the CRT group. GU/GI toxicity grade ≥2 occurred in 43 (48.3%) RT patients and 38 (45.2%) CRT patients.

CONCLUSIONS

The organ-preserving strategy with CRT was feasible and tolerable in this patient population, and the achieved LC and OS were satisfactory in comparison to the RC cohort and literature.

Outcome of radiotherapy for invasive bladder cancer in older patients - not candidates for or decline cystectomy

PURPOSE

Retrospective study to assess the role of radiotherapy (RT) in bladder cancer (BC) in patients who decline cystectomy or for whom it was contraindicated, regarding BC related events.

MATERIALS AND METHODS

A cross-sectional study, of patients with BC treated with RT, with or without chemotherapy was carried out, during the period March 2005 to March 2017, excluding patients who performed cystectomy. BC-related events were defined as haematuria, episodes requiring intravesical irrigations or transurethral resection or admission in Urology Department caused by symptoms related to BC.

RESULTS

Fifty-eight patients were included, 44 men and 14 women, whose median age at diagnosis was 78.3 years. Nine patients were treated with a RT dose below 50Gy (20-45Gy), in relation with non-resectable disease, nodal involvement, presence of metastasis or poor performance status. Forty-nine patients were treated with a RT dose above 50Gy (maximum 60.4Gy). The median follow-up time was 24 months, with BC-specific survival at 1/5 years of 87.5%/0.0% and 83.1%/33.9% in the group treated with RT dose below 50Gy and above 50Gy, respectively. Results revealed that the number of events decreased significantly after RT for both groups. For the two groups, the median of events before RT was 2.0, decreasing for 1.0 after RT (RT dose<50Gy: P=0.011; RT dose≥50Gy: P=0.026).

CONCLUSION

This therapeutic approach can have an important role in older patients with bladder cancer, in terms of reducing disease related events. Symptom control was significantly achieved in both therapeutic groups.

[Optimizing the management of bladder cancer in older patients]

AIM

To define and present potential improvements for the management of bladder cancer in older patients.

METHOD

Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: bladder cancer, treatment, BCG, chemotherapy, cystectomy, and elderly.

RESULTS

The oncological principles of medico-surgical management of bladder cancer do not differ according to age. On the other hand, the patient comorbidities have been likely to alter the tolerance of these treatments. At the NMIBC stages, no adaptation of the standard treatment has demonstrated any interest. At the MIBC stages, the prognosis was improved by geriatric multidisciplinary perioperative management.

CONCLUSION

The indications and principles of surgical treatments must be identical regardless of the patient age. At the NMIBC stages, adjuvant therapy, including BCG therapy, should not be questioned because of the age of the patient. On the other hand, at the localized MIBC stages, neoadjuvant and adjuvant chemotherapy should not be considered as a standard and their indications assessed individually after geriatric assessment.

Challenges Facing Radiation Oncologists in The Management of Older Cancer Patients: Consensus of The International Geriatric Radiotherapy Group

The management of older cancer patients remains difficult because of data paucity. Radiation oncologists need to identify potential issues which could affect treatment of those patients. A workshop was organized in Barcelona among international radiation oncologists with special interest in the management of older cancer patients on April 22, 2018. The following consensus was reached: 1. Older cancer patients often faced unconscious discriminating bias from cancer specialists and institutions because of their chronological age. 2. Advances in radiotherapy techniques have allowed patients with multiple co-morbidities precluding surgery or systemic therapy to achieve potential cure in early disease stages. 3. The lack of biomarkers for frailty remains an impediment to future research. 4. Access to healthcare insurance and daily transportation remains an issue in many countries; 5. Hypofractionation, brachytherapy, or stereotactic techniques may be ideally suited for older cancer patients to minimize transportation issues and to improve tolerance to radiotherapy. 6. Patients with locally advanced disease who are mentally and physically fit should receive combined therapy for potential cure. 7. The role of systemic therapy alone or combined with radiotherapy for frail patients needs to be defined in future clinical trials because of targeted agents or immunotherapy may be less toxic compared to conventional chemotherapy.