“Sir, in order to cure your bladder cancer, we need to remove your bladder.” Nobody wants to hear these words. However, when advanced bladder cancer is diagnosed, the most common treatment in the United States is radical cystectomy, surgical removal of the bladder. This surgery also often involves making a “neobladder” (new bladder) out of bowel, a major procedure. Patients who are elderly or in poor health cannot tolerate this type of surgery. In addition, many otherwise healthy patients refuse to have a radical cystectomy, opting to preserve their bladder. What other treatment options are there for bladder cancer?
A study just published in the New England Journal of Medicine confirms quite good results with radiation therapy (RT) in combination with chemotherapy: http://www.nejm.org/doi/full/10.1056/NEJMoa1106106. In this randomized phase III trial, half of the 360 patients with muscle-invasive bladder cancer received RT alone and the other half received chemo+RT. After long-term follow-up (almost six years), the 5-year survival rate was 48% in the group treated with chemoRT vs 35% in the group treated with RT alone. Of note, the chemotherapy medicines in this trial (mitomycin and fluorouracil) are different than the cisplatin or carboplatin-based chemotherapy most commonly used currently in this country.
ChemoRT for bladder-preserving treatment of patients with bladder cancer is not new. Prior studies have shown very good results with chemoRT using cisplatin-based combinations: http://www.ncbi.nlm.nih.gov/pubmed/9060542?dopt=Abstract. Before the patient starts chemoRT, it’s also critical for the urologist (surgeon) to remove the visible tumor within the bladder in a procedure called transurethral resection of bladder tumor (TURBT for short) for maximum chance of cure. This type of surgery is performed through a cystoscope, minimally invasive in comparison to the major surgery of a radical cystectomy. Acute complications from chemoRT include fatigue, urinary and bowel irritation which resolve over a few weeks in ~90% of patients. Chronic bladder or bowel toxicities requiring surgery to fix them are much less common. A minority of patients need their bladder ultimately removed if it is not functioning well due to fibrosis (scarring) after chemoRT.
The bottom line for patients with locally invasive bladder cancer is that there are reasonable treatment options besides major surgery. The combination of RT and chemotherapy can result in 5-year survival rates that can be quite similar to those after radical cystectomy (40-50%), despite these patients being in much worse condition prior to treatment than those who are deemed healthy enough to undergo radical cystectomy.
- Patrick Maguire MD