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Goonewardene SS, Bahl A, Persad R. Role of neoadjuvant chemotherapy in muscle-invasive bladder cancer: Clinical and cost effectiveness. JOURNAL OF CLINICAL UROLOGY 2015. [DOI: 10.1177/2051415814554334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | - Amit Bahl
- North Bristol National Health Service Trust, UK
| | - Raj Persad
- North Bristol National Health Service Trust, UK
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2
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Abstract
Radical cystectomy is a standard treatment for patients with muscle-invasive bladder cancer. The presence of occult micrometastatic disease is responsible for both local and distant failure after radical surgery. Postoperative administration of chemotherapy in bladder cancer patients can theoretically give the same survival advantage demonstrated in patients with breast and colon cancer. Studies evaluating adjuvant chemotherapy in patients with pT3-pT4 and/or pN+ M0 disease have major deficiencies in terms of sample sizes, early stopping of patient entry, statistical analyses, reporting of results and drawing conclusions. A recent meta-analysis including all previously published randomized trials concludes that, currently, there is insufficient evidence to reliably recommend adjuvant chemotherapy. The results of appropriately sized randomized trials are needed before any definitive conclusions can be drawn.
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Affiliation(s)
- Cora N Sternberg
- Department of Medical Oncology, San Camillo and Forlanini Hospitals, Nuovi Padiglioni IV Floor, Circonvallazione Gianicolense 87, 00152 Rome, Italy.
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3
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Leow JJ, Martin-Doyle W, Rajagopal PS, Patel CG, Anderson EM, Rothman AT, Cote RJ, Urun Y, Chang SL, Choueiri TK, Bellmunt J. Adjuvant chemotherapy for invasive bladder cancer: a 2013 updated systematic review and meta-analysis of randomized trials. Eur Urol 2013; 66:42-54. [PMID: 24018020 DOI: 10.1016/j.eururo.2013.08.033] [Citation(s) in RCA: 295] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 08/13/2013] [Indexed: 12/21/2022]
Abstract
CONTEXT The role of adjuvant chemotherapy remains poorly defined for the management of muscle-invasive bladder cancer (MIBC). The last meta-analysis evaluating adjuvant chemotherapy, conducted in 2005, had limited power to fully support its use. OBJECTIVE To update the current evidence of the benefit of postoperative adjuvant cisplatin-based chemotherapy compared with control (ie, surgery alone) in patients with MIBC. EVIDENCE ACQUISITION A comprehensive literature review was performed to identify all randomized controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy with control for patients with MIBC. The search included the Medline, Embase, Cochrane Central Register of Controlled Trials databases, and abstracts from the American Society of Clinical Oncology meetings up to May 2013. An updated systematic review and meta-analysis was performed. EVIDENCE SYNTHESIS A total of 945 patients included in nine RCTs (five previously analyzed, one updated, and three new) were examined. For overall survival, the pooled hazard ratio (HR) across all nine trials was 0.77 (95% confidence interval [CI], 0.59-0.99; p=0.049). For disease-free survival, the pooled HR across seven trials reporting this outcome was 0.66 (95% CI, 0.45-0.91; p=0.014). This disease-free survival benefit was more apparent among those with positive nodal involvement (p=0.010). CONCLUSIONS This updated and improved meta-analysis of randomized trials provides further evidence of an overall survival and disease-free survival benefit in patients with MIBC receiving adjuvant cisplatin-based chemotherapy after radical cystectomy.
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Affiliation(s)
- Jeffrey J Leow
- Harvard School of Public Health, Harvard University, Boston, MA, USA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Padma S Rajagopal
- Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Chirayu G Patel
- Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Erin M Anderson
- Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Andrew T Rothman
- Harvard School of Public Health, Harvard University, Boston, MA, USA
| | - Richard J Cote
- Department of Pathology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Yuksel Urun
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Steven L Chang
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA; Division of Urology, Brigham and Women's Hospital, Boston, MA, USA
| | - Toni K Choueiri
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Joaquim Bellmunt
- Bladder Cancer Center, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA; University Hospital del Mar-IMIM, Barcelona, Spain.
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4
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Castellano D, Carles J, Esteban E, Trigo JM, Climent MÁ, Maroto JP, García del Muro X, Font A, Paz-Ares L, Arranz JÁ, Bellmunt J. Recommendations for the optimal management of early and advanced urothelial carcinoma. Cancer Treat Rev 2012; 38:431-41. [DOI: 10.1016/j.ctrv.2011.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 10/18/2011] [Accepted: 10/22/2011] [Indexed: 10/15/2022]
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5
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Yafi FA, Cury FL, Kassouf W. Organ-sparing strategies in the management of invasive bladder cancer. Expert Rev Anticancer Ther 2010; 9:1765-75. [PMID: 19954288 DOI: 10.1586/era.09.151] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bladder cancer is the second most common genitourinary malignancy. Radical cystectomy and pelvic lymphadenectomy is the standard of care in the management of muscle-invasive bladder cancer. However, recently, bladder-preservation trials conducted by both single- and multi-institutional groups have gained momentum because of comparable survival and recurrence rates in select patients. While single-modality therapies have failed to provide adequate results, multimodal combination therapies consisting of a thorough transurethral resection with radiotherapy and concomitant chemotherapy have been promising. Careful patient selection, maximum transurethral resection of bladder tumor, cystoscopic evaluation of response with prompt salvage cystectomy for nonresponders and strict long-term follow-up for complete responders constitute the hallmarks of optimal bladder-preservation protocols. Advances in molecular-targeted therapy, chemotherapy and radiotherapy hold promise to improve survival and local control and decrease side effects and toxicity.
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Affiliation(s)
- Faysal A Yafi
- Department of Surgery (Urology), McGill University, Montreal, Quebec, Canada.
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6
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Mak RH, Zietman AL, Heney NM, Kaufman DS, Shipley WU. Bladder preservation: optimizing radiotherapy and integrated treatment strategies. BJU Int 2008; 102:1345-53. [DOI: 10.1111/j.1464-410x.2008.07981.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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7
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Effective bladder preservation strategy with low-dose radiation therapy and concurrent intraarterial chemotherapy for muscle-invasive bladder cancer. ACTA ACUST UNITED AC 2008; 26:156-63. [PMID: 18683571 DOI: 10.1007/s11604-007-0211-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study was to evaluate retrospectively the toxicity and response, bladder preservation, and survival of patients with muscle-invasive bladder cancer treated with multimodality therapy consisting of low-dose radiation therapy (RT) and concurrent intraarterial chemotherapy (IACT). METHODS AND MATERIALS . Between November 1999 and July 2005, a total of 27 consecutive, previously untreated patients with muscle-invasive bladder cancer underwent transurethral bladder tumor resection followed by concurrent low-dose RT and IACT. Patients who achieved a complete response (CR) were followed up closely without further therapy, and patients who did not achieve a CR underwent further treatment. RESULTS Complete response was achieved in 22 of 27 patients (81%). Of these 22 patients, 7 developed recurrences, and 3 died of their disease. In five patients who did not achieve CR, one died from bone metastases. The 3-year overall survival rate was 81%, with a median follow-up time of 27 months; and 22 of 27 patients (81%) with a preserved bladder were tumor-free at the last follow-up. Three patients (11%) developed grade 3 acute hematological toxicity. CONCLUSION Multimodality therapy consisting of low-dose RT and concurrent IACT for muscle-invasive bladder cancer can achieve survival rates similar to those in patients treated with radical cystectomy, with successful bladder preservation and minimal adverse effects.
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8
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Chemotherapy for muscle-invasive bladder cancer treated with definitive radiotherapy: persisting uncertainties. ACTA ACUST UNITED AC 2008; 5:444-54. [DOI: 10.1038/ncponc1159] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 12/11/2007] [Indexed: 11/09/2022]
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9
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Merseburger AS, Kuczyk MA. The value of bladder-conserving strategies in muscle-invasive bladder carcinoma compared with radical surgery. Curr Opin Urol 2007; 17:358-62. [PMID: 17762631 DOI: 10.1097/mou.0b013e3282c4afa0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Patients with muscle-invasive bladder cancer will practically all develop progression, often associated with severe side effects including pain, dysuria or macrohematuria. Recent reports demonstrate multimodality bladder-sparing approaches as primary treatment for muscle-invasive bladder cancer. RECENT FINDINGS Bladder-conserving strategies include thorough transurethral resection of the bladder tumor, external beam radiation therapy and chemotherapy. It has been shown that survival rates are similar to those of radical cystectomy series; additionally, a substantial number of patients survive with an intact bladder. The high costs, close cooperation between clinical specialists and a highly compliant patient need to be taken into consideration, however. SUMMARY Nowadays, the good long-term results after radical cystectomy with the creation of an orthotopic neobladder make the substantial advantage of a bladder-preserving strategy questionable when the patient's quality of life is addressed. Multimodality bladder-conserving strategies are a therapeutic option for selected patients; however, radical cystectomy remains the gold standard of treatment.
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Milosevic M, Gospodarowicz M, Zietman A, Abbas F, Haustermans K, Moonen L, Rödel C, Schoenberg M, Shipley W. Radiotherapy for Bladder Cancer. Urology 2007; 69:80-92. [PMID: 17280910 DOI: 10.1016/j.urology.2006.05.060] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Accepted: 05/03/2006] [Indexed: 11/24/2022]
Abstract
The radiotherapy panel met to develop international consensus about the optimal use of radiotherapy, alone or in combination with surgery and chemotherapy, in the radical treatment of patients with bladder cancer. A consensus meeting of experts in the treatment of bladder cancer was convened by the Société Internationale d'Urologie (SIU). The radiotherapy committee, which had international representation from 6 countries, performed a critical review of the English-language literature and developed evidence-based guidelines for the use of radiotherapy in the treatment of patients with bladder cancer. The strength of the evidence supporting each recommendation was ranked according to a 4-point scale. Consensus statements were developed that address (1) the effectiveness of radiotherapy in the treatment of bladder cancer, (2) the most appropriate patients for curative treatment with radiotherapy, (3) the optimal method of delivery of radiotherapy, (4) the best radiation prescription for treating bladder cancer, and (5) optimal management of the patient's condition after radiotherapy has been provided. Radiotherapy is effective treatment for selected patients with bladder cancer; it produces long-term disease control with preservation of normal bladder function. Modern radiotherapy treatment techniques offer the potential to improve cure rates and reduce adverse effects. All patients in whom the condition is newly diagnosed should be assessed in a multidisciplinary setting, where the relative merits of surgery, radiotherapy, and chemotherapy can be considered on an individual basis with the aim of optimizing overall outcomes.
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Affiliation(s)
- Michael Milosevic
- Radiation Medicine Program, Princess Margaret Hospital, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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11
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Efstathiou JA, Zietman AL, Kaufman DS, Heney NM, Coen JJ, Shipley WU. Bladder-sparing approaches to invasive disease. World J Urol 2006; 24:517-29. [PMID: 17082940 DOI: 10.1007/s00345-006-0114-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Although immediate radical cystectomy remains the standard of care for invasive bladder cancer, a large body of international experience from single institutions and cooperative groups has accumulated, suggesting favorable results with bladder-sparing approaches in appropriately selected patients. Modern selective bladder preservation with trimodality therapy, consisting of transurethral resection of the bladder tumor, radiation, and chemotherapy, can achieve complete response rates of 60-80%, 5-year survival rates of 50-60%, and survival rates with an intact bladder of 40-45%. Although no randomized comparisons between cystectomy and trimodality therapy exist, long-term data confirm that the 10-year overall and disease-specific survival rates for patients in bladder-sparing protocols are comparable to outcomes reported in contemporary cystectomy series. In addition, quality of life studies have demonstrated that the retained native bladder functions well. Thus, trimodality therapy with careful cystoscopic surveillance and with prompt cystectomy for invasive recurrences has emerged as a legitimate alternative to extirpative surgery. Future work will continue to optimize the bladder-sparing regimen while limiting toxicity.
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Affiliation(s)
- Jason A Efstathiou
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Cox 3, Boston, MA 02114, USA.
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12
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Goebell PJ, vom Dorp F, Rübben H. Stellenwert der systemische Chemotherapie des Harnblasenkarzinoms. Urologe A 2006; 45:586, 588-90, 592-3. [PMID: 16710678 DOI: 10.1007/s00120-006-1058-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Almost half of the patients with muscle invasive disease already harbor at the time of their first diagnosis occult or distant metastases. Systemic disease has a poor prognosis with a long term survival of less than 10%. The administration of systemic chemotherapy aims to improve the course of locally advanced or metastatic disease.A survival benefit of 5% for patients receiving neoadjuvant and 9-11% using adjuvant chemotherapy is in the first scenario minimal, in the adjuvant setting to be noteworthy. The MVAC-schedule and the Gemcitabine/Cisplatin-combination chemotherapy have to be regarded as standard for induction chemotherapy. However, the 5-year survival rates with 15 or 13% are disappointing.Thus, prognostic factors gain importance since with their consideration significant differences in survival rates can be found. Hope is provided by a novel class of substances, the target-specific drugs, which selectively interfere with the cascade of steps involved in tumorigenesis.
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Affiliation(s)
- P J Goebell
- Westdeutsches Tumorzentrum (WTZE), Essen, Germany.
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13
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Abstract
BACKGROUND Controversy exists as to whether adjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite a number of randomised controlled trials. OBJECTIVES To evaluate the effect of adjuvant chemotherapy in invasive bladder cancer. We conducted a systematic review and meta-analysis of updated individual patient data from all available randomised controlled trials comparing local treatment plus adjuvant chemotherapy versus the same local treatment alone. SEARCH STRATEGY MEDLINE and Cancerlit searches were supplemented with information from registers and hand searching meeting proceedings and also by discussion with relevant trialists and organisations. They have been regularly updated until September 2004. SELECTION CRITERIA Trials that aimed to randomise patients with biopsy proven invasive (i.e. clinical stage T2-T4a) transitional cell carcinoma of the bladder to receive local definitive treatment with or without adjuvant chemotherapy were eligible for inclusion. DATA COLLECTION AND ANALYSIS We collected, validated and re-analysed updated data on all randomised patients from all available randomised trials, including 491 patients from 6 RCTs. For all outcomes, we obtained overall pooled hazard ratios using the fixed effects model. To explore the potential impact of trial design, we pre-planned analyses that grouped trials by important aspects of their design that might influence the treatment effect. To investigate any differences in effect by pre-defined patient sub-groups, we used a stratified logrank analysis on the primary endpoint of survival. MAIN RESULTS Analyses were based on 491 patients from six trials, representing 90% of all patients randomised in cisplatin-based combination chemotherapy trials and 66% of patients from all eligible trials. The power of this meta-analysis is clearly limited. The overall hazard ratio for survival of 0.75 (95%CI 0.60-0.96, p=0.019) suggests a 25% relative reduction in the risk of death for chemotherapy compared to that on control. Cox regression suggests that small imbalances in patient characteristics do not bias the results in favour of chemotherapy. However, the impact of trials that stopped early, of patients not receiving allocated treatments or not receiving salvage chemotherapy is less clear. AUTHORS' CONCLUSIONS This IPD meta-analysis provides the best evidence currently available on the role of adjuvant chemotherapy for invasive bladder cancer. However, at present there is insufficient evidence on which to reliably base treatment decisions. These results highlight the urgent need for further research into the use of adjuvant chemotherapy. The results of appropriately sized randomised trials, such as the ongoing EORTC-30994 trial are needed before any definitive conclusions can be drawn.
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Affiliation(s)
- Claire L Vale
- MRC Clinical Trials UnitMeta‐analysis Group222 Euston RoadLondonUKNW1 2DA
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Fokdal L, Høyer M, von der Maase H. Radical radiotherapy for urinary bladder cancer: treatment outcomes. Expert Rev Anticancer Ther 2006; 6:269-79. [PMID: 16445379 DOI: 10.1586/14737140.6.2.269] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The exact value of radiotherapy in the treatment of muscle-invasive bladder cancer is difficult to establish, as most studies exploring this issue are retrospective with different procedures for selecting patients for treatment, as well as varying treatment strategies. An estimate of the 5-year overall survival rate following radiotherapy is approximately 35% in consecutive-selected patients and approximately 25% in negative-selected patients.
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Affiliation(s)
- Lars Fokdal
- Department of Oncology, Aarhus University Hospital, DK-8000 C Aarhus, Denmark
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15
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Adjuvant chemotherapy in invasive bladder cancer: a systematic review and meta-analysis of individual patient data Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. Eur Urol 2005; 48:189-199; discussion 199-201. [PMID: 15939530 DOI: 10.1016/j.eururo.2005.04.005] [Citation(s) in RCA: 320] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Accepted: 04/06/2005] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To evaluate the effect of adjuvant chemotherapy in invasive bladder cancer. METHODS : We conducted a systematic review and meta-analysis of updated individual patient data from all available randomised controlled trials comparing local treatment plus adjuvant chemotherapy versus the same local treatment alone. RESULTS Analyses were based on 491 patients from six trials, representing 90% of all patients randomised in cisplatin-based combination chemotherapy trials and 66% of patients from all eligible trials. The power of this meta-analysis is clearly limited. The overall hazard ratio for survival of 0.75 (95% CI 0.60-0.96, p = 0.019) suggests a 25% relative reduction in the risk of death for chemotherapy compared to that on control. Cox regression suggests that small imbalances in patient characteristics do not bias the results in favour of chemotherapy. However, the impact of trials that stopped early, of patients not receiving allocated treatments or not receiving salvage chemotherapy is less clear. CONCLUSIONS This IPD meta-analysis provides the best evidence currently available on the role of adjuvant chemotherapy for invasive bladder cancer. However, at present there is insufficient evidence on which to reliably base treatment decisions. These results highlight the urgent need for further research into the use of adjuvant chemotherapy. The results of appropriately sized randomised trials, such as the ongoing EORTC-30994 trial are needed before any definitive conclusions can be drawn.
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16
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Abstract
BACKGROUND Controversy exists as to whether neoadjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite randomised controlled trials (RCTs) involving over 3000 patients. OBJECTIVES To conduct a systematic review and meta-analysis of individual patient data to evaluate the effect of neoadjuvant chemotherapy on survival in patients with this invasive bladder cancer. SEARCH STRATEGY MEDLINE and Cancerlit searches were supplemented with information from registers and by hand searching meeting proceedings and also by discussion with relevant trialists and organisations. These have been regularly updated until June 2003. SELECTION CRITERIA Trials that aimed to randomise patients with biopsy proven invasive (i.e. clinical stage T2-T4a) transitional cell carcinoma of the bladder to receive local definitive treatment with or without neoadjuvant chemotherapy were eligible for inclusion. DATA COLLECTION AND ANALYSIS We collected, validated and re-analysed updated data on all randomised patients from all available randomised trials, including 3005 patients from 11 RCTs. For all outcomes, we obtained overall pooled hazard ratios using the fixed effects model. To explore the potential impact of trial design we pre-planned analyses that grouped trials by important aspects of their design that might influence the treatment effect. To investigate any differences in effect by pre-defined patient subgroups we used a stratified logrank analysis on the primary endpoint of survival. MAIN RESULTS These results include data from one extra trial and so update those in the original publication ABC 2003. Platinum based combination chemotherapy showed a significant benefit on overall survival with a combined hazard ratio (HR) 0.86 (95% CI 0.77 to 0.95, p=0.003); 14% reduction in the risk of death; 5% absolute benefit at 5 years (95% CI 1 to 7%); overall survival increased from 45% to 50%. This effect was observed irrespective of the type of local treatment and did not vary between subgroups of patients. The HR for all trials, including those that used single-agent cisplatin, tended to favour neoadjuvant chemotherapy (HR= 0.89, 95% CI 0.81 to 0.98, p=0.022). Although platinum based combination chemotherapy was beneficial, there was no clear evidence to support the use of single-agent platinum, indeed there was significant difference in the effect between these groups of trials (p=0.029). AUTHORS' CONCLUSIONS This improvement in survival encourages the use of platinum based combination chemotherapy for patients with invasive bladder cancer.
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Busby JE, Evans CP. Old friends, new ways: revisiting extended lymphadenectomy and neoadjuvant chemotherapy to improve outcomes. Curr Opin Urol 2004; 14:251-7. [PMID: 15300144 DOI: 10.1097/00042307-200409000-00002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Standard therapy for muscle-invasive bladder cancer is radical cystectomy and pelvic-lymph-node dissection. Because 50% of patients will die at 5 years as a result of micrometastases, improvements have been sought to increase the survival rates. Two specific approaches include administration of neoadjuvant chemotherapy or extending the boundaries of the lymph-node dissection. We reviewed the current literature to define present trends and studies that involve these adjunct treatments. RECENT FINDINGS The benefits of extended lymphadenectomy have been demonstrated by several groups. These include mapping nodal metastatic sites and defining the requisite number of nodes removed to optimize survival. Though not universal, it is frequently concluded that increasing the number of nodes removed improves survival without worse morbidity. Neoadjuvant chemotherapy has been proposed to eliminate occult cancer cells outside the margins of resection. Results have been variable and modest, though emerging data from the Southwest Oncology Group may further support such an approach and improve organ preservation. SUMMARY Extended lymphadenectomy has consistently shown benefit with minimal morbidity and should be considered--especially in cystectomy patients that are T3. The results from neoadjuvant chemotherapy are more modest. Further studies await further elucidation to confirm this.
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Chester JD, Hall GD, Forster M, Protheroe AS. Systemic chemotherapy for patients with bladder cancer – current controversies and future directions. Cancer Treat Rev 2004; 30:343-58. [PMID: 15145509 DOI: 10.1016/j.ctrv.2003.12.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Many localised, superficial bladder cancers can be effectively controlled. However, disease which has spread to nodes outside the pelvis or to distant organs is generally incurable and systemic therapies, rather than surgery, are appropriate. Combination chemotherapy based around established cytotoxic drugs such as cisplatin has proven benefit in palliating symptoms and prolonging survival in responsive patients with advanced disease. Combination chemotherapies which include newer cytotoxic drugs such as gemcitabine provide the potential for equivalent efficacy with less toxicity than established regimens. Between the extremes of superficial and advanced disease, muscle-invasive bladder cancers have traditionally been treated, with curative intent, by radical surgery or radiotherapy. However, newly published data suggest, for the first time, genuine survival benefits from peri-operative chemotherapy. This article reviews the evidence for cisplatin-based chemotherapy in advanced disease, assesses the potential benefits of newer cytotoxic drugs, discusses the latest evidence pertaining to peri-operative chemotherapy in muscle-invasive disease, and looks forward to potential new biological agents in the systemic therapy of bladder cancer.
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Affiliation(s)
- John D Chester
- Cancer Research UK Clinical Centre in Leeds, St. James' University Hospital, Beckett Street, Leeds LS9 7TF, UK.
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Prout GR, Wesley MN, McCarron PG, Chen VW, Greenberg RS, Mayberry RM, Edwards BK. Survival experience of black patients and white patients with bladder carcinoma. Cancer 2004; 100:621-30. [PMID: 14745881 DOI: 10.1002/cncr.11942] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Blacks are less likely than whites to develop bladder carcinoma. However, once they are diagnosed, black patients experience poorer survival. The authors investigated which factors were related to survival differences in black patients and white patients with bladder carcinoma stratified by extent of disease. METHODS A population-based cohort of black patients with bladder carcinoma and a random sample of frequency-matched white patients with bladder carcinoma, stratified by age and gender, were identified through cancer registry systems in Atlanta, New Orleans, and San Francisco/Oakland. Patients had no previous cancer history and were ages 20-79 years at the time they were diagnosed with bladder carcinoma in 1985-1987. Medical records were reviewed at initial diagnosis, and 77% of patients were interviewed. Tumor grade, T classification, and other variables, including age, socioeconomic position, symptom duration, smoking history, and comorbidities, were recorded. Survival of black patients and white patients by extent of disease was modeled using Cox regression analysis. RESULTS A greater proportion of black patients had histologic types of tumors that were associated with poorer survival. Among those with pure urothelial carcinoma, black patients had greater extent of disease at the time of diagnosis. Within specific extent-of-disease categories, there was some evidence of poorer survival for black patients with T2 tumors and strong evidence of poorer survival among those with T3 tumors compared with white patients. Black patients with muscle-invasive carcinoma who died within 6 months of diagnosis tended to present with life-threatening symptoms. Black patients and white patients did not differ with respect to diagnostic tests performed or therapy given. CONCLUSIONS Black patients with bladder carcinoma had poorer survival due to greater extent of disease at diagnosis and a higher proportion of more aggressive histologies compared with white patients. Within urothelial carcinomas, by extent of disease (clinical/pathologic stage) these black/white survival differences were limited to patients with muscle invasion (T2 and T3 tumors).
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Affiliation(s)
- George R Prout
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland 20892-8315, USA
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Winquist E, Kirchner TS, Segal R, Chin J, Lukka H. Neoadjuvant Chemotherapy for Transitional Cell Carcinoma of the Bladder: A Systematic Review and Meta-Analysis. J Urol 2004; 171:561-9. [PMID: 14713760 DOI: 10.1097/01.ju.0000090967.08622.33] [Citation(s) in RCA: 237] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Despite local therapy most patients with muscle invasive transitional cell carcinoma (TCC) of the bladder die of systemic relapse, indicating a need for effective adjunctive systemic treatment. We determined whether neoadjuvant chemotherapy improved overall survival. MATERIALS AND METHODS A systematic review and meta-analysis were performed of all known randomized controlled trials (RCTs) of neoadjuvant chemotherapy for stages II and III TCC conducted between 1984 and 2002. RESULTS A total of 16 eligible RCTs (3,315 patients) were identified. Of these trials 11 (2,605 patients) provided data suitable for a meta-analysis of overall survival and the pooled HR was 0.90 (95% CI 0.82 to 0.99, p = 0.02). Eight trials used cisplatin based combination chemotherapy and the pooled HR was 0.87 (95% CI 0.78 to 0.96, p = 0.006), consistent with an absolute overall survival benefit of 6.5% (95% CI 2 to 11%) from 50% to 56.5%. Reported progression-free survival data were insufficient for meta-analysis but they appeared concordant with overall survival results. Mortality due to combination chemotherapy was 1.1%. A major pathological response was associated with improved overall survival in 4 trials. CONCLUSIONS Neoadjuvant cisplatin based chemotherapy improves overall survival in muscle invasive TCC. The size of the effect is modest and combination chemotherapy can be administered safely without adverse outcomes resulting in delayed local therapy. An optimal chemotherapy regimen was not identified and newer regimens have not been tested in RCTs in this setting. Further efforts to identify the patients most likely to benefit from neoadjuvant therapy are necessary to optimize its use.
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Kuczyk M, Turkeri L, Hammerer P, Ravery V. Is there a role for bladder preserving strategies in the treatment of muscle-invasive bladder cancer? Eur Urol 2003; 44:57-64. [PMID: 12814676 DOI: 10.1016/s0302-2838(03)00150-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Single modality bladder sparing therapy for muscle-invasive bladder cancer, including transurethral resection, systemic chemotherapy or radiotherapy have been demonstrated to result in insufficient local control of the primary tumor as well as decreased long-term survival of the patients when compared to radical cystectomy. Therefore, multimodality treatment protocols that aim at bladder preservation and involve all of the aforementioned approaches have been established. Arguments for combining systemic chemotherapy with radiation are to sensitize tumor tissue to radiotherapy and to eradicate occult metastases that have already developed in as many as 50% of patients at the time of first diagnosis. It has been shown that the clinical outcome observed with this approach approximates that after radical cystectomy. Additionally, a substantial number of patients survive with an intact bladder. However, bladder preserving approaches are costly, and require close co-operation between different clinical specialists as well as very close follow-up. The good long-term results obtained after cystectomy and creation of an orthotopic neobladder make the possible advantage of a bladder preservation strategy questionable in consideration of quality of life issues. Additionally, side effects related to bladder sparing therapy may result in an increased morbidity and mortality in those patients who in fact need to undergo surgery due to recurrent or progressive disease. Multimodality bladder sparing treatment is a therapeutic option that can be offered to the patient at centres that have a dedicated multidisciplinary team at their disposal. However, radical cystectomy remains the standard of care for muscle-invasive bladder tumors.
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Affiliation(s)
- M Kuczyk
- Department of Urology, Hannover University Medical School, D-30625 Hannover, Germany.
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22
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Abstract
BACKGROUND Controversy exists as to whether neoadjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite randomised controlled trials of more than 3000 patients. We undertook a systematic review and meta-analysis to assess the effect of such treatment on survival in patients with this disease. METHODS We analysed updated data for 2688 individual patients from ten available randomised trials. FINDINGS Platinum-based combination chemotherapy showed a significant benefit to overall survival (combined hazard ratio [HR] 0.87 [95% CI 0.78-0.98, p=0.016]; 13% reduction in risk of death; 5% absolute benefit at 5 years [1-7]; overall survival increased from 45% to 50%). This effect was observed irrespective of the type of local treatment, and did not vary between subgroups of patients. The HR for all trials, including those using single-agent cisplatin, tended to favour neoadjuvant chemotherapy (HR=0.91, 95% CI 0.83-1.01) although this tendency was not significant (p=0.084). Although platinum based combination chemotherapy was beneficial, there was no evidence to support the use of single-agent platinum; indeed, there was a significant difference in the effect between these groups of trials (p=0.044). INTERPRETATION This improvement in survival encourages the use of platinum-based combination chemotherapy for patients with invasive bladder cancer.
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Juffs HG, Moore MJ, Tannock IF. The role of systemic chemotherapy in the management of muscle-invasive bladder cancer. Lancet Oncol 2002; 3:738-47. [PMID: 12473515 DOI: 10.1016/s1470-2045(02)00930-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Patients with localised but muscle-invasive transitional-cell carcinoma (TCC) of the bladder are at high risk of relapse and death from metastatic disease after local treatment by cystectomy, radiation, or both. Despite improvements in treatment, patients with metastatic TCC have a median survival of about a year. TCC is quite sensitive to chemotherapy, and patients are able to tolerate newer regimens such as gemcitabine plus cisplatin better than older regimens such as methotrexate, vinblastine, doxorubicin, and cisplatin. However, the role of chemotherapy in the management of locally advanced muscle-invasive TCC remains uncertain. Most trials of neoadjuvant or adjuvant chemotherapy have shown no significant improvement in survival, but many of these studies had suboptimum design, evaluated chemotherapy that was less effective than regimens in current use, and had sample sizes that were too small for important changes in survival to be detected or ruled out. Recent trials show trends in the direction of improved survival when optimum chemotherapy is used. Large trials that recruit more than 1000 patients are required to assess the effectiveness of adjunctive chemotherapy, and a large intergroup trial is in progress. Other trials should address the role of molecular markers in selecting patients for chemotherapy. Whenever possible, chemotherapy for locally advanced muscle-invasive TCC should be given in the context of a well-designed clinical trial.
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Affiliation(s)
- Helen G Juffs
- Princess Margaret Hospital, Ontario, Toronto, Canada
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24
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Abstract
OBJECTIVE To assess in detail and evaluate the effect on survival of delays in the diagnosis and treatment of cancer (which might lead to a worse prognosis), dividing the delay from onset of symptoms to first treatment into several components, comprising patient delay, general practitioner (GP) delay, and two or more periods of hospital delay. PATIENTS AND METHODS Data were prospectively collected on 1537 new cases of urothelial cancer in the West Midlands from 1 January 1991 to 30 June 1992. Death information was obtained from the West Midlands Cancer Intelligence Unit and censored at 31 July 2000. The influence of delay times on survival was explored. RESULTS The median delay from onset of symptoms to GP referral was 14 days (Delay 1), from GP referral to first hospital attendance was 28 days (Delay 2), and from first hospital attendance to first transurethral resection of bladder tumour was 20 days (Delay 3). The median hospital delay (Delay 2 + 3) was 68 days and the median total delay (Delay 1 + 2 + 3) was 110 days. Patients with a shorter Delay 1 had a lower tumour stage and a 5% better 5-year survival. Patients with a shorter hospital delay had worse survival; total delay had no effect on survival. CONCLUSIONS There was significantly better survival for patients referred to hospital within 14 days of the onset of symptoms. The relationship between delay and survival in bladder cancer is complex. Hospital delays may be influenced more by comorbidity than by the characteristics of the tumour. However, the adverse effects of delay seem to be most pronounced for patients with pT1 tumours.
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Affiliation(s)
- D M A Wallace
- Department of Urology, The Queen Elizabeth Hospital, Birmingham, UK.
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25
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Hussain SA, Moffitt DD, Glaholm JG, Peake D, Wallace DM, James ND. A phase I-II study of synchronous chemoradiotherapy for poor prognosis locally advanced bladder cancer. Ann Oncol 2001; 12:929-35. [PMID: 11521797 DOI: 10.1023/a:1011133820532] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The management of locally advanced bladder cancer remains controversial with poor local control with radiotherapy alone. Synchronous chemotherapy regimens have yielded encouraging results in other primary sites. PATIENTS AND METHODS Patients with T2-T4a N0/NX M0 bladder cancer were entered into this single centre phase I-II study. Patients received radiotherapy to 55 Gy in 20 fractions over four weeks. Concurrent chemotherapy was given with Mitomycin C 12 mg/m2 day 1 and 5-fluorouracil 500 mg/m2/24 hours weeks one and four of radiotherapy for five or seven days on each occasion. RESULTS Thirty-one patients entered the trial from March 1998 to December 1999 (22: 5-day; 9: 7-day schedule). Median age was 68 (range 58-79) years, 23 males and 8 females. T2: 9 (29%); T3a: 4 (12%); T3b: 9 (29%); T4: 9 (29%); TCC grade 2: 8 (26%) and grade 3: 23 (74%); 14 of 31 had hydronephrosis. Ten of thirty-one had a GFR < 50 ml/min. Toxicity was mild to moderate with the five-day schedule. More severe toxicity was seen with the seven-day schedule: five of nine patients failed to complete planned therapy. Pathological complete response rate at three months was 74% (5-day regimen) and 50% (7-day regimen). Overall 12-month survival was 65%. CONCLUSION Chemoradiotherapy with the five-day schedule is feasible with acceptable toxicity in poor prognosis patients. A randomised trial is being launched.
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Affiliation(s)
- S A Hussain
- CRC Institute for Cancer Studies. University of Birmingham, Edgbaston, United Kingdom
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26
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Brown AL, Zietman AL, Shipley WU, Kaufman DS. AN ORGAN-PRESERVING APPROACH TO MUSCLE-INVADING TRANSITIONAL CELL CANCER OF THE BLADDER. Hematol Oncol Clin North Am 2001; 15:345-58, vii. [PMID: 11370497 DOI: 10.1016/s0889-8588(05)70216-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Bladder-preserving treatment for muscle-invasive disease is based on the response of the tumor to induction combined modality therapy. In the future, an organ-conserving approach will be widely offered as a safe and reasonable alternative to radical cystectomy.
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Affiliation(s)
- A L Brown
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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27
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Chemotherapy as an Adjunct to Surgery. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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28
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Zietman AL, Shipley WU, Kaufman DS. Organ-conserving approaches to muscle-invasive bladder cancer: future alternatives to radical cystectomy. Ann Med 2000; 32:34-42. [PMID: 10711576 DOI: 10.3109/07853890008995908] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In the USA radical surgery remains the golden standard for invasive bladder cancer. Yet in most other areas of surgical oncology the trend of the 1990s has been towards organ conservation with chemoradiation with or without limited local surgery. Patients with breast, oesophageal, anal, lung and larynx cancer are routinely offered conservative therapies as valid options in the management of their diseases but bladder stands apart from the crowd. Evidence is presented here to show that this need not be the case. Four older randomized trials failed to show a survival advantage when immediate cystectomy was compared with radiation followed by salvage cystectomy, if required. Five and 8-year survival rates for clinically staged patients treated by transurethral resection and chemoradiation (trimodality therapy) in several modern, large and mature series show survival rates comparable to those reported in contemporary radical cystectomy series. Eighty per cent of those alive 5 years after chemoradiation still retain their native bladder. Although superficial relapse occurs in 20% of cases, it remains responsive to BCG (Bacilles bilie de Calmette-Guerin) in the manner of de novo superficial disease. Quality-of-life studies show that the retained bladder functions well. At the Massachusetts General Hospital and in the multicentre prospective trials, less than 1% of patients needed cystectomy for bladder morbidity. It is of note that continent diversions may be performed as salvage after contemporary radiation therapy. Trimodality therapy is a novel and contemporary approach that owes little to the radiation treatment offered in the 1970s. While it will never entirely take the place of radical cystectomy, it should be offered as a reasonable alternative to patients with a new diagnosis of bladder cancer. This multidisciplinary approach will allow uro-oncology to keep in step with the oncological vanguard.
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Affiliation(s)
- A L Zietman
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
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29
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SHIPLEY WILLIAMU, KAUFMAN DONALDS, HENEY NIALLM, ALTHAUSEN ALEXF, ZIETMAN ANTHONYL. AN UPDATE OF COMBINED MODALITY THERAPY FOR PATIENTS WITH MUSCLE INVADING BLADDER CANCER USING SELECTIVE BLADDER PRESERVATION OR CYSTECTOMY. J Urol 1999. [DOI: 10.1016/s0022-5347(05)68582-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- WILLIAM U. SHIPLEY
- From the Departments of Radiation Oncology, Medical Oncology and Urology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - DONALD S. KAUFMAN
- From the Departments of Radiation Oncology, Medical Oncology and Urology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - NIALL M. HENEY
- From the Departments of Radiation Oncology, Medical Oncology and Urology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - ALEX F. ALTHAUSEN
- From the Departments of Radiation Oncology, Medical Oncology and Urology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - ANTHONY L. ZIETMAN
- From the Departments of Radiation Oncology, Medical Oncology and Urology, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts
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30
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Abstract
Until now, radical cystectomy has been considered the most effective treatment for invasive bladder cancer. However it fails to cure more than 50% of patients and can result in a mediocre quality of life. In an effort to improve cure rates, combined modality regimens have been investigated. Despite the preliminary results of early clinical trials, randomized trials have most often failed to show any benefit from neoadjuvant or adjuvant chemotherapy or radiotherapy. One of the major progress brought by radiotherapy has been the wide use of conservative treatment in several cancer, and in the recent years promising results have been published with concomitant radio-chemotherapy. The use of conservative approach in bladder cancer now appears to be a tangible reality for selected patients, but this combined modality have not yet been tested in randomized trials.
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Affiliation(s)
- M Housset
- Service d'oncologie-radiothérapie, hôpital Tenon, Paris, France
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32
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Abstract
Since 1985, the gold standard regimen for metastatic tumours of the urothelial tract is a combination of methotrexate, vinblastine, doxorubicin and cisplatin (M-VAC protocol). Randomised studies have shown the superiority of the M-VAC regimen over cisplatin alone or in combination with cyclophosphamide and doxorubicin. The limited gain in survival shows that, although chemosensitive, metastatic tumours cannot be cured by the available drug combinations. Amongst new cytotoxic drugs in development, paclitaxel and gemcitabine are likely to be involved in the standard regimen of the future. The studies published to date do not support the routine use of chemotherapy in the neo-adjuvant or adjuvant setting for the management of early stage urothelial tumours.
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Affiliation(s)
- S Culine
- Département de médecine, Centre régional de lutte contre le cancer Val d'Aurelle-Paul-Lamarque, Montpellier, France
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33
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Pavone-Macaluso M, Hall RR, Hirao Y, Kamidono S, Miyanaga N, de Mulder PH, Naito S, Shipley WU, Tsushima T. The role of neoadjuvant or adjuvant chemotherapy for invasive bladder cancer Is there a benefit for survival or preserving the bladder? Urol Oncol 1998; 4:154-67. [PMID: 21227221 DOI: 10.1016/s1078-1439(99)00010-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/1999] [Indexed: 10/18/2022]
Affiliation(s)
- M Pavone-Macaluso
- Universita di Palermo, Department of Urology, via Villa Trabia 9, 90141, Palermo, Italy
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35
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Muscle-Invasive Bladder Cancer: Transurethral Resection and Radiochemotherapy as an Organ-Sparing Treatment Option. ACTA ACUST UNITED AC 1998. [DOI: 10.1007/978-3-642-60258-0_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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36
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Shipley WU, Zietman AL, Kaufman DS, Althausen AF, Heney NM. Invasive bladder cancer: treatment strategies using transurethral surgery, chemotherapy and radiation therapy with selection for bladder conservation. Int J Radiat Oncol Biol Phys 1997; 39:937-43. [PMID: 9369144 DOI: 10.1016/s0360-3016(97)00461-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Combined modality therapy has become the standard oncologic approach to achieve organ preservation in many malignancies. METHODS AND MATERIALS Although radical cystectomy has been considered as standard treatment for invasive bladder carcinoma in the United States, good results have been recently reported from several centers using multimodality treatment, particularly in patients with clinical T2 and T3a disease who do not have a ureter obstructed by tumor. RESULTS The components of the combined treatment are usually transurethral resection of the bladder tumor (TURBT) followed by concurrent chemotherapy and radiation therapy. Following an induction course of therapy a histologic response is evaluated by cystoscopy and rebiopsy. Clinical "complete responders" (tumor site rebiopsy negative and urine cytology with no tumor cells present) continue with a consolidation course of concurrent chemotherapy and radiation. Those patients not achieving a clinical complete response are recommended to have an immediate cystectomy. Individually the local monotherapies of radiation, TURBT, or multidrug chemotherapy each achieve a local control rate of the primary tumor of from 20 to 40%. When these are combined, clinical complete response rates of from 65 to 80% can be achieved. Seventy-five to 85% of the clinical complete responders will remain with bladders free of recurrence of an invasive tumor. CONCLUSIONS Bladder conservation trials using combined modality treatment approaches with selection for organ conservation by response of the tumor to initial treatment report overall 5-year survival rates of approximately 50%, and a 40-45% 5-year survival rate with the bladder intact. These modern multimodality bladder conservation approaches offer survival rates similar to radical cystectomy for patients of similar clinical stage and age. Bladder-conserving therapy should be offered to patients with invasive bladder carcinoma as a realistic alternative to radical cystectomy by experienced multimodality teams of urologic oncologists.
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Affiliation(s)
- W U Shipley
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA
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37
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McCaffrey JA, Herr HW. Adjuvant and Neoadjuvant Chemotherapy for Urothelial Carcinoma. Surg Oncol Clin N Am 1997. [DOI: 10.1016/s1055-3207(18)30297-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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38
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Management of invasive bladder cancer: Strategies of combined modality treatment. Semin Radiat Oncol 1997. [DOI: 10.1016/s1053-4296(97)80059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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39
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Abstract
BACKGROUND: Bladder cancer is one of the most common malignancies in Western society. In the United States, approximately 10,000 of these patients present with invasive disease, and more progress from superficial bladder cancer. METHODS: The authors review the literature on systemic treatment for both localized and metastatic bladder cancer, and they include their experience in defining approaches to various stages of disease. RESULTS: Cisplatin-based combination chemotherapy is the most effective systemic approach for advanced bladder cancers, although few patients are cured. Neoadjuvant, perspective, and adjuvant trials, as well as concurrent chemoradiation studies, are in progress to attempt to demonstrate better outcomes. CONCLUSIONS: The combination of systemic chemotherapy and definitive local therapy may have a useful role in the management of locally advanced bladder cancers, but optimal schedules and true survival benefit have not been established.
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Affiliation(s)
- M Javle
- Division of Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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40
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Five-year Followup of a Prospective Trial of Radical Cystectomy and Neoadjuvant Chemotherapy: Nordic Cystectomy Trial 1. J Urol 1996. [DOI: 10.1016/s0022-5347(01)66042-7] [Citation(s) in RCA: 188] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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41
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Raghavan D. Perioperative chemotherapy for invasive bladder cancer--what should we tell our patients? J Urol 1996; 155:1246-7. [PMID: 8632541 DOI: 10.1016/s0022-5347(01)66231-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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42
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Koiso K, Shipley W, Keuppens F, Baert L, Hall R, Hudson MA, Khoury S, Kubota Y, Kubota Y, van Poppel H. The status of bladder-preserving therapeutic strategies in the management of patients with muscle-invasive bladder cancer. Int J Urol 1995; 2 Suppl 2:49-57. [PMID: 7553305 DOI: 10.1111/j.1442-2042.1995.tb00479.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The recommended treatment for medically fit patients with muscle-invading bladder cancer is usually radical cystectomy. However, transurethral resection of the tumor, partial cystectomy, irradiation and systemic chemotherapy are each effective in some patients. These latter treatments allow bladder preservation and cure as an alternative to radical cystectomy although when used unselectively the survival rates are inferior to those of radical cystectomy. The updated results of conservative surgery, radiation therapy and systemic chemotherapy as monotherapy, as well as strategies of combined modality treatment were reviewed. Based on this review many areas of consensus were reached which include: 1. The primary goal of any treatment for a patient with muscle-invading bladder cancer is survival; bladder preservation in the interest of quality of life is a secondary objective. 2. Only a small proportion of carefully selected patients may be cured by transurethral surgery alone, or by partial cystectomy alone. 3. Radiation therapy is currently the standard bladder-preserving therapy against which all other bladder-preserving methods must be compared. 4. Systemic chemotherapy as monotherapy is inadequate and cannot be recommended. 5. The addition of cisplatin-containing systemic chemotherapy to radiation therapy or conservative surgery appears to improve local control. While no multi-modality therapeutic regimen has yet been shown to be clearly optimal with regard to local efficacy and minimizing toxicity, monotherapy for bladder preservation is probably not desirable as a routine approach. 6. Deferring the patient from immediate cystectomy does not appear to compromise survival, nor does the addition of primary systemic chemotherapy appear to significantly increase the morbidity of cystectomy or radiotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K Koiso
- University of Tsukuba Institute of Clinical Medicine, Department of Urology, Ibaraki, Japan
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43
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Sternberg CN, Raghaven D, Ohi Y, Bajorin D, Herr H, Kato T, Kuroda M, Logothetis CH, Scher H, Splinter TA. Neoadjuvant and adjuvant chemotherapy in advanced disease--what are the effects on survival and prognosis? Int J Urol 1995; 2 Suppl 2:76-88. [PMID: 7553308 DOI: 10.1111/j.1442-2042.1995.tb00482.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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44
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Gospodarowicz MK, Quilty PM, Scalliet P, Tsujii H, Fossa SD, Horenblas S, Isaka S, Prout GR, Shipley WU, Wijnmaalen AJ. The place of radiation therapy as definitive treatment of bladder cancer. Int J Urol 1995; 2 Suppl 2:41-8. [PMID: 7553304 DOI: 10.1111/j.1442-2042.1995.tb00478.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- M K Gospodarowicz
- Princess Margaret Hospital, Department of Radiation Oncology, Toronto, Ontario, Canada
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45
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c MKG, cc PMQ, cc PS, Tsujii H, Fossa SD, Horenblas S, Isaka S, Prout GR, Shipley WU, Wijnmaalen AJ, Crazvford ED, Jones WG, Kawai T. THE PLACE OF RADIATION THERAPY AS DEFINITIVE TREATMENT OF BLADDER CANCER. Int J Urol 1995. [DOI: 10.1111/j.1442-2042.1995.tb00071.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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46
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c KK, cc WS, cc FK, Baert L, Hall R, Hudson MA, Khoury S, Kubota Y, Kubota Y, Poppel HV. THE STATUS OF BLADDER. P. RESERVING THERAPEUTIC STRATEGIES IN THE MANAGEMENT OF PATIENTS WITH MUSCLE-INVASIVE BLADDER CANCER. Int J Urol 1995. [DOI: 10.1111/j.1442-2042.1995.tb00072.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bosl GJ, Fair WR, Herr HW, Bajorin DF, Dalbagni G, Sarkis AS, Reuter VE, Cordon-Cardo C, Sheinfeld J, Scher HI. Bladder cancer: advances in biology and treatment. Crit Rev Oncol Hematol 1994; 16:33-70. [PMID: 8074800 DOI: 10.1016/1040-8428(94)90041-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Integrating systemic chemotherapy in the treatment of patients with invasive bladder cancer is essential to improve survival because the majority of deaths are from systemic relapse. However, as experience with invasive tumors evolves, it is clear that treatment recommendations need to be tailored to an individual patient based on metastatic risk and, ideally, sensitivity to treatment. For those with tumors that do not extend through the bladder wall, standard therapy remains radical surgery. Nevertheless, encouraging results are being reported with increasing frequency using strategies designed to preserve bladder function through a variety of means. Crucial to the recommendation of a specific approach for an individual is improving our ability to define prognosis prior to initiating treatment. Patients with a high risk of systemic recurrence generally require chemotherapy, although the optimal route of integration, pre vs. post-operatively, remains controversial. In those patients who require it, chemotherapy can be administered more safely with the concomitant administration of hematopoietic growth factors. These factors alone, however, are unlikely to improve overall survival. Crucial to the latter effort will be the identification of more active agents, improving our understanding of intrinsic and acquired resistance to chemotherapy, and better delivery of the chemotherapeutic agents currently available. Of equal importance, is the enrollment of patients in clinical trials. These can include large scale randomized comparisons with using a survival end-point, as well as new therapies in high risk populations. The latter would include patients with advanced T3b, T4 and N+ disease, with a high risk of metastatic failure, and low complete response proportions to presently available regimens.
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Affiliation(s)
- G J Bosl
- Division of Solid Tumor Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021
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Abstract
Neoadjuvant therapy has come to play an increasingly prominent role in the treatment of cancer. Originally defined as systemic therapy given before local treatment, the concept has been extended to include radiation therapy given before surgery. Potential advantages include improved local and distant control, direct evaluation, and organ-sparing treatment. Potential disadvantages include increased toxicity and cost, potential delay in effective treatment, and obscuring of pathologic staging. Neoadjuvant therapy in cancer treatment may be viewed in three categories: tumors in which neoadjuvant treatment has been shown effective, thus becoming standard therapy; tumors in which it has been shown to facilitate organ-sparing, and tumors in which its utility has not been shown. For patients with osteogenic sarcoma, for example, preoperative chemotherapy and limb salvage therapy have become the standard of care. Response to chemotherapy, ascertained by histologic review of the surgical specimen, can be used to tailor postoperative chemotherapy. In patients with advanced laryngeal squamous cell carcinoma, neoadjuvant chemotherapy followed by radiation has permitted laryngeal preservation in a majority of patients without compromising overall survival. Phase II and III studies conducted in women with breast cancer have demonstrated promising results for neoadjuvant chemotherapy given before radiation therapy and/or surgery. Phase III studies to compare neoadjuvant therapy to standard therapy in patients with breast cancer are underway. For neoadjuvant therapy, as with other innovations in cancer treatment, it is crucial that a new strategy must be compared closely to standard therapy in terms of recurrence, survival, and impact on organ sparing, as well as quality of life and treatment costs.
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Affiliation(s)
- E L Trimble
- National Cancer Institute, Bethesda, Maryland
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Fosså SD, Waehre H, Aass N, Jacobsen AB, Olsen DR, Ous S. Bladder cancer definitive radiation therapy of muscle-invasive bladder cancer. A retrospective analysis of 317 patients. Cancer 1993; 72:3036-43. [PMID: 8221571 DOI: 10.1002/1097-0142(19931115)72:10<3036::aid-cncr2820721028>3.0.co;2-b] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The role of radiation therapy as curative treatment of muscle-invasive bladder cancer was to be analyzed. METHODS From 1980-1990, 308 patients with transitional cell carcinoma of the urinary bladder received definitive pelvic radiation therapy (nominal standardized dose greater than or equal to 1700 ret). T categorization was based on clinical examination assessing the palpability of the bladder tumor and its extent (TNM 1978/1982). RESULTS The cancer-specific 5-year survival rate for all patients was 24% (crude survival, 20%). The 135 patients with T2/T3a tumors lived significantly longer (5-year survival, 38%) than those with greater than or equal to T3b tumors (5-year survival, 14%). In the former group of patients, age (75 years and younger versus older than 75 years) was significantly correlated with a favorable outcome. The cancer-specific 2-year survival was significantly correlated to clinical response assessed 3-4 months after radiation therapy was 72%, 38%, and 10% in cases of complete response, partial response, and no response/inevaluability, respectively. In a multivariate analysis, the T categorization, patient age, serum creatinine level (less than or equal to 150 mumol/l versus greater than 150 mumol/l), and radiation therapy schedule predicted the 5-year survival rate. CONCLUSIONS The clinical T category (< or = T3a versus > or = T3b), based on bimanual palpation, represents an important prognostic parameter, if done by clinicians experienced in onco-urology. High-dose radiation therapy offers a reasonable chance for long-term survival in patients with T2/T3 tumors confined to the bladder wall, especially in patients younger than 76 years. Greater than or equal to 80% of patients with more extended tumors (greater than or equal to T3b) and those older than 75 years of age are not curable by radiation therapy alone. In these patients palliative treatment modalities should be considered, in particular if cisplatin-based chemotherapy is not feasible.
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Affiliation(s)
- S D Fosså
- Department of Medical Oncology and Radiotherapy, Norwegian Radium Hospital, Oslo
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