Pre-emptive (neo-adjuvant) chemotherapy prior to radical radiotherapy for fit septuagenarians with bladder cancer: age itself is not a contra-indication

Muscle-Invasive Bladder Cancer in Elderly-Unfit Patients with Concomitant Illness: Can a Curative Radiation Therapy be Delivered?

Aims and background

There is no standard treatment for elderly-unfit patients with muscle-invasive bladder cancer. Pelvic irradiation alone is an usual approach in this instance, and some reports have demonstrated that curative radiotherapy is feasible in elderly patients. To our knowledge, no data exist about the feasibility of a curative treatment in elderly patients with concomitant illness and a Charlson Comorbidity Index (an index of comorbidity that includes age) greater than 2. The main purpose of the present study was to establish the feasibility of irradiation in a cohort of elderly patients in poor general condition.

Methods

The records of 45 elderly-unfit patients (median age, 75 years; range, 70-85), with a comorbid Charlson score >2, treated with curative dose, planned continuous-course, external beam radiotherapy for muscle-invasive bladder cancer were reviewed. The patients were treated to a median total dose of 60 Gy (range, 56–64), with an average fractional dose of 190 ± 10 cGy using megavoltage (6–15 MV). All patients were treated with radiation fields encompassing the bladder and grossly involved lymph nodes with a radiographic margin of at least 1.5 cm.

Results

No treatment-related mortality and clinically insignificant acute morbidity was recorded. No patient was hospitalized during or after the irradiation because of gastrointestinal or urogenital side effects. In one patient a week rest from therapy was necessary due a febrile status. Median survival was 21.5 months; overall 3- and 5-year survival was 36% and 19.5%, respectively.

Conclusions

Elderly-unfit patients with comorbidities and >70 years of age can be submitted to radical pelvic irradiation. The results observed in this retrospective analysis have encouraged us to use non-palliative radiotherapy doses in these patients with muscle-invasive bladder cancer.

Role of neoadjuvant chemotherapy in muscle-invasive bladder cancer: Clinical and cost effectiveness

Background:

Bladder cancer is one of the most common cancers in the Western world, with associated significant mortality. Once proven to be muscle invasive, radical therapy is required.

Objective:

We reviewed the literature associated with clinical effectiveness of neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer.

Methods:

We conducted a systematic literature review of papers related to the search terms neoadjuvant chemotherapy, muscle invasive bladder cancer and clinical effectiveness; from 1984 through April 2014. We used the search terms of (neoadjuvant chemotherapy) AND (muscle invasive bladder cancer). We included primary research, but only included secondary research if it was a systematic review or meta-analyses. Papers outside this category were not included.

Results:

From the literature review, we found that the benefits of neoadjuvant chemotherapy for muscle-invasive bladder cancer are wide-ranging. This includes a greatly improved response rate, including complete response and improved survival rate. Potential disadvantages of NAC include less accurate staging, delays in curative surgery (risk is greater, if delay > 12 weeks) in non-responders and the well-known fact that non-responders will fare worse, later on.

Conclusions:

In conclusion, NAC followed by radical therapy is the gold standard for muscle-invasive bladder tumours, for patients whom are sufficiently fit; however, there are many unanswered questions. As yet, this intervention has not been examined by the National Institute for Health and Care Excellence.

Primary bladder preservation treatment for urothelial bladder cancer

BACKGROUND

Significant advancements have occurred in surgical procedures and chemoradiation therapy for bladder preservation.

METHODS

This review addresses primary treatment options for bladder cancer, including an overview of bladder-sparing strategies.

RESULTS

Surgical series demonstrate that highly selected patients with cT2N0M0 urothelial bladder cancers can be managed with partial cystectomy and bilateral pelvic lymphadenectomy. For patients with cT2N0M0 to cT4aN0M0 urothelial bladder cancers, neoadjuvant chemotherapy followed by radical cystectomy or maximal transurethral resection of the bladder tumor (TURBT) followed by chemoradiation therapy results in equivalent survival rates. However, each treatment option has a different impact on quality of life. Current chemoradiation therapy trials are evaluating novel approaches to improve outcomes.

CONCLUSIONS

Maximal TURBT followed by chemoradiation therapy demonstrated equivalent survival with radical cystectomy while preserving bladder function in the majority of patients. Future efforts will be directed toward improving survival and quality of life.

Treatment of patients with metastatic urothelial cancer "unfit" for Cisplatin-based chemotherapy

PURPOSE

Cisplatin-based combination chemotherapy is considered standard first-line treatment for patients with metastatic urothelial carcinoma. However, a large proportion of patients with metastatic urothelial carcinoma are considered "unfit" for cisplatin. The purpose of this review is to define unfit patients and to identify treatment options for this subgroup of patients.

PATIENTS AND METHODS

In this review, the criteria used to define unfit patients are explored and the results of prospective clinical trials evaluating chemotherapeutic regimens in unfit patients are summarized.

RESULTS

Several phase II trials and a single, large phase III trial have explored chemotherapeutic regimens for the treatment of unfit patients with metastatic urothelial carcinoma. Heterogeneous eligibility criteria have been used to define unfit patients in these studies. A uniform definition of unfit is proposed on the basis of the results of a survey of genitourinary medical oncologists. According to this definition, unfit patients would meet at least one of the following criteria: Eastern Cooperative Oncology Group performance status of 2, creatinine clearance less than 60 mL/min, grade ≥ 2 hearing loss, grade ≥ 2 neuropathy, and/or New York Heart Association Class III heart failure.

CONCLUSION

Additional studies to optimize treatment for this important subset of patients are needed. A uniform definition of unfit patients will lead to more uniform clinical trials, enhanced ability to interpret the results of these trials, and a greater likelihood of developing a viable strategy for regulatory approval.

Primary treatment of pelvic osteosarcoma: Report of five cases

Five patients, ages 12 to 20 years, with nonresectable primary (Patients 2, 3, and 5) and metastatic (Patients 1 and 4) pelvic osteosarcomas were treated with intraarterial cisplatin and concurrent radiation therapy from 1983 to 1987. Long-term local tumor control was achieved in all five patients. Patients 1 and 3 are alive with no evidence of local recurrence or metastatic disease at 77 and 56 months of follow-up, respectively, since diagnosis of the pelvic tumor. Patients 2, 4, and 5 died of metastatic lung disease at 25, 39, and 12 months, respectively, after diagnosis of the pelvic tumor. Patient 4 had no clinical or radiologic evidence of local recurrence. Control of tumor growth in patients with pelvic osteosarcomas can be achieved with regional chemotherapy and concurrent radiation therapy. These patients also should receive adjuvant intensive systemic chemotherapy to increase the probability of eliminating potential subclinical metastatic disease.

Radiation therapy of the older patient

Radiotherapy has a major role in the multidisciplinary approach to cancer therapy. It is widely used for curative and palliative treatment of cancer involving various sites. Radiotherapy is of particular benefit to older and frail cancer patients as an alternative to surgery and to systemic therapy. The available data on the sensitivity of normal tissues to radiotherapy in elderly patients strongly suggest that older patients with good functional status tolerate radiotherapy as well as younger patients and have comparable tumor response and survival rates. Aggressive radiotherapy should not be withheld from older patients because of chronological age alone.

La cistectomia nell'anziano: Radical cystectomy in the elderly patient

It is certainly true that an increase in the average life span has caused a greater percentage of elderly people to visit urological departments. From April 1989 to December 1996, 52 patients over 75 years underwent radical cystectomy and urinary diversion. The numerical analysis of our experience has highlighted the fact that in operated patients the incidence and mortality caused by cardiovascular diseases were no higher than those found in other people of the same age.

Management of prostate and bladder cancer in the elderly

The management of prostate and bladder cancer in the elderly will increasingly require clinicians to judge the impact on comorbidity and toxicity of the proposed therapy in order to make sound management decisions. As PSA-based screening has rapidly increased, physicians are increasingly challenged to decide the upper age limits for such screening and therapy. Bladder cancer management in the elderly differs little from that offered to the younger patient and the new therapeutic developments may improve the risk-to-benefit ratio of treating advanced disease. It is clear that as the US population ages, management of prostate and bladder cancer will become an increasingly common dilemma for the urologic practitioner.

Age and sex are independent predictors of 5-fluorouracil toxicity. Analysis of a large scale phase III trial

BACKGROUND

Cancer is most common in older age groups, but little information is available with regard to the impact of age on chemotherapy toxicity. This study was undertaken to determine if age is an independent risk factor for 5-fluorouracil (5-FU) toxicity.

METHODS

Toxicity data from a prospective, randomized, multiinstitution trial of 5-FU-based treatment for advanced colorectal cancer were analyzed. Toxicity for each organ system was graded. Individual organ toxicity proportions were compared using chi-square analysis. A logistic regression was performed using age (younger than 70 years vs. 70 years or older), sex, treatment arm, performance status, and length of therapy as model parameters to predict severe toxicity. Toxicity in 331 patients was analyzed.

RESULTS

Advanced age was significantly associated with the occurrence of any severe toxicity (58 vs. 36%, P < 0.001), leukopenia (24 vs. 10%, P < 0.005), diarrhea (24 vs. 14%, P = 0.01), vomiting (15 vs. 5%, P = 0.01), severe toxicity in more than 2 organ systems (10 vs. 3%, P = 0.02), and treatment mortality (9 vs. 2%, P = 0.01). By univariate analysis, age (P < 0.001) and sex (P < 0.0001) were independent predictors of severe toxicity. Twenty-two of 27 women age 70 years or older had severe toxicity.

CONCLUSIONS

Age 70 years or older and sex are risk factors for severe toxicity from 5-FU-based chemotherapy. Advanced age does not contraindicate the use of this type of chemotherapy, but close monitoring for multiple organ toxicities and vigorous supportive care of those with toxicity are required. Dosing decisions in older patients are difficult and must integrate assessments of organ function, comorbidities, overall physical status, and goals of treatment, in an effort to ensure the best possible outcome for these patients.

The combination of cis-platin based chemotherapy and radiation in the treatment of muscle-invading transitional cell cancer of the bladder

Radical cystectomy is the standard of care for patients with muscle-invading transitional cell carcinoma of the bladder. More limited surgery is only useful in highly selected patients and radiation therapy alone gives overall local-control rates under 40%. Phase II studies have shown that when radiation and trans-urethral surgery are combined with cis-platin based chemotherapy local-control rates increase such that the majority of patients preserve a tumor-free functional bladder. Up to 85% of patients selected for bladder sparing therapy on the basis of their initial response to chemo-radiation may keep their bladders. This figure could increase further when other powerful prognostic factors such as the presence of hydronephrosis, the presence of carcinoma in situ, and DNA ploidy are also taken into account in initial patient selection. The activity of cisplatin combinations in metastatic disease is not in doubt with up to 50% response rates generally reported. The hope that this will translate into the eradication of micrometastatic disease (known to be present in up to 40% of patients at diagnosis) has yet to be borne out. Those randomized trials so far reported have not shown any survival advantage when combined-modality therapy is compared to radiation alone. The addition of combination chemotherapy to radiation does not increase bladder morbidity but carries a considerable systemic penalty. Thus, despite promising Phase II studies, until local control and survival benefit is proven in a randomized trial it should continue to be regarded as experimental.

Chemotherapy for urothelial tract malignancies: breaking the deadlock

Chemotherapy treatments for urothelial tract tumors have improved to the point that some patients are enjoying long-term disease-free survival. Moreover, with currently available agents and combinations, and with our increased application of clinical and biologic prognostic factors, we are refining our ability to select appropriate therapies for individual patients. We have learned that once the decision is made to use combination chemotherapy, adequate doses should be used. This can be facilitated by the coadministration of hematopoeitic growth factors. Recently completed phase II trials have confirmed that higher doses and dose rates may increase response proportions of and in particular, the proportion of complete responses. The finding that granulocyte colony stimulating factor enhances the sensitivity of tumor cells to methotrexate in vitro and to other agents studied against urothelial tumors implanted in nude mice implies an expanded role for these compounds. However, because non-hematologic toxicities are still important, it is unlikely that simple escalation of all components a four drug regimen such as of M-VAC (cisplatin, methotrexate, vinblastine, and doxorubicin) will have a significant impact on survival. In addition, as more is learned about the pharmacokinetic and pharmacodynamic relationships of the active agents, it appears that better schedules can be designed to improve the therapeutic index of the compounds. Ultimately we will be able to determine drug sensitivities, both at the start of therapy and as it evolves during treatment, that will allow a better selection of a particular chemotherapeutic regimen. For example, mdr1 induction appears to play a significant role in the therapy for treatment-resistant tumors. The availability of a number of active salvage regimens that are not constrained by this mechanism hints that changes in drug sequencing and drug scheduling may provide a significant improvement in outcome. While established combination chemotherapy regimens should be considered standard therapy in appropriately selected patients, promising strategies and new agents need to be investigated if we are to "break the deadlock" that has appeared in the treatment of urothelial tumors. These investigations can be performed safely in a well-controlled fashion to enable the identification of new regimens and to compare promising strategies with appropriate control populations in randomized trials.

Bladder carcinoma--a 20-year review of radical irradiation therapy

Between 1967 and 1986, 319 patients, judged unsuitable for cystectomy, were scheduled to receive curative radiation treatment for transitional cell cancer of the urinary bladder. Crude and corrected 5-year survival for all stages were 18% and 28%, respectively. Corrected 5-year survival by stage was: T1-57%, T2-31%, T3-16% and T4-6%. Fifty-seven patients (18%) never completed the scheduled treatment and all but two of them died in a short time from tumour progression. Local response could be evaluated in 179 of the 262 patients, who completed the radiation treatment. In 130 patients (73%) complete local response was observed and 49 patients (27%) had persistent tumour. Corrected 5-year survival in the responder group was 53% compared to 8% in the non-responder group. Intestinal complications occurred in 51 patients, of whom 24 were operated upon and another four died before operation from radiation-induced intestinal complications. More than 80% of all intestinal and/or urinary tract complications were observed within 3 years after irradiation. During this period, special attention should be paid to detect and treat radiation complications to prevent fistula formation or perforation, with poor prognosis. The dose per radiation fraction and the radiation technique appeared to be the most important factors for the development of intestinal complications.

Cisplatin combination chemotherapy for elderly patients with urothelial tumours

The proportion of cancer patients who receive potentially curative therapy declines with increasing chronological age. Between January 1979 and January 1988, 36 patients aged from 76 to 84 years (median 78) consented to cisplatin combination chemotherapy. Eighteen patients received 1 to 7 cycles of adjuvant chemotherapy (median 5). This resulted in a drop in creatinine clearance rate from 70 +/- 28.5 ml/min to 49 +/- 20 ml/min. Eight patients (44%) are alive without evidence of disease, with a whole group median survival of 23 months. The dose intensity of cisplatin was found to predict recurrence. Eighteen other patients were treated for metastatic disease; 39% had an objective response after receiving 2 to 9 cycles (median 7). Only 2 patients (11%) are alive and free of disease. In this group no significant kidney damage occurred and the dose intensity of cisplatin did not predict response. Treatment resulted in a significant sepsis rate (39%) and 6 patients (17%) withdrew from treatment because of toxicity. It was concluded that cisplatin combination chemotherapy can be administered without treatment-related death and its efficacy is similar to that in younger patients. Age should not exclude patients from the potential benefit of such therapy. An important cause of reduced benefit from chemotherapy among elderly patients may be the reduced dosage of cisplatin.

Prognostic factors for survival of patients with advanced urothelial tumors treated with methotrexate, vinblastine, doxorubicin, and cisplatin chemotherapy

Between February 1983 and February 1986, 132 patients with advanced urothelial tract tumors were treated with methotrexate, vinblastine, Adriamycin (doxorubicin), and cisplatin (M-VAC) chemotherapy. Analysis of prognostic factors for survival of the first 92 patients was undertaken using the Cox proportional hazards model. Normal alkaline phosphatase and high Karnofsky performance status (KPS) were predominant for long survival. Patients 60 years or older at initiation of therapy were likely to survive longer than younger patients, perhaps indicating physician selectivity of older patients for this therapy, and those with initial hemoglobin in the normal range were also likely to survive longer. The additional 40 patients' data were used to validate the model. Clinical implications of the prognostic factors are discussed.