treatment options for cancer of the bladder

The Treatment of Cancer of the

Bladderwww.aboutcancer.com

Bladder Cancer

Understanding bladder cancer

Treatment options of bladder cancer (surgery, radiation, chemotherapy)

Radiation techniques and side effects

NCCN.org

www.nccn.org

Treatment of Bladder CancerEarly Stage: Surgery (TUR or transurethral resection of the bladder followed by intravesical chemotherapy (i.e. Mitomycin) or immunotherapy (BCG)

Muscle Invading Cancer: Surgery (total or partial cystectomy) may be preceded by chemotherapy or followed by chemotherapy and/ or radiation depending on the stage. If the patient is not a candidate for surgery then chemotherapy or radiation may be alternatives

Advanced: chemotherapy or radiation

cystoscope

bladderurethra

prostate

Cystoscopy

TURB

Trans Urethral Resection

Chemotherapy into the Bladder

Treatment of Bladder CancerEarly Stage: Surgery (TUR or trans urethral resection of the bladder followed by intravesical chemotherapy (i.e. Mitomycin) or immunotherapy (BCG)



Surgery

Surgery

Total Cystectomy Partial Cystectomy

Surgery Results

Large single-center experiences report a 45%-66% 5-year overall survival after radical cystectomy. In recent studies, the mortality rate after radical cystectomy is less than or equal to 3%, and the complication rate varies between 25% and 57% in the first 30 days after surgery.

With surgery alone, 20%-30% of patients with pT2 disease, 40%-60% of patients with pT3 disease, and 70%-90% of patients with pT4 disease will develop distant metastases or local recurrences and die of their cancer; consequently, 5-year survival rates after radical cystectomy in contemporary series average 66% for pT2 disease, 35% for pT3 disease, and 27% for pT4 disease.

Surgery Results

Stage Relapse Survival

pT2 20-30% 66%pT3 40-60% 35%pT4 70-90% 27%

Treatment of Bladder CancerEarly Stage: Surgery (TUR or trans urethral resection of the bladder followed by intravesical chemotherapy (i.e. Mitomycin) or immunotherapy (BCG)



Radiation Therapy

Radiation for Bladder Cancer

• Post Operative radiation for high risk cancers

• Radiation plus chemotherapy to cure cancers and avoid removing the bladder (bladder preservation protocols)

• Radiation alone or with chemotherapy for patients who are not candidates for major surgery

• For metastatic cancer

PostOperative Radiation

International Journal of Radiation Oncology • Biology • Physics, Vol. 45, Issue 3, p221–222, 1999

Status at 5 Years

Cystectomy Cystectomy + 50Gy

Pelvic Control78% 88%

Cancer Specific Survival40% 62%

NCCN Guidelines 2014? Role for PostOp Radiation

After a Partial Cystectomy

Consider adjuvant Radiation (category 2B) or Chemotherapy (category 2B) based on pathology report showing high risk features

(pT3-4, or positive nodes or positive margins or high-grade)

if no neoadjuvant was given

NCCN Guidelines 2014 for T2

• Radical Cystectomy (+/- neoadjuvant chemotherapy) Category 1

• Partial Cystectomy (highly selected) +/- chemotherapy

• Bladder preservation protocol : Category 2B

• If not suitable for major surgery then TURBT or chemoradiation or chemotherapy alone

Bladder Preservation Protocol

• Maximal TURB• Chemoradiation to 40-45Gy• Repeat Cystoscopy

• If no disease complete chemoradiation go 60-66Gy

• If residual tumor then cystectomy

Robert Miller

Long term survival following radical cystectomy for TCC of the bladder—comparison between primary and radical cystectomy.

Addla SK, Naidu P, Maddineni SB, et al. J Urol 2009;181(4):(abstr 1754).

Treatment 5 Year Survival

Primary Cystectomy 45.5%Salvage Cystectomy 42%

Combined-modality treatment and selective organ preservation in invasive bladder cancer

Rödel C, Grabenbauer GG, Kuhn R, et al. J Clin Oncol 2002;20(14):3061–3071.

5- and 10-year survivals of 51% and 31% and included patients deemed inoperable.

Chemoradiation trials of Bladder Cancer from the RTOG

• Complete Response: 59 – 81%• 80% of Long Term Survivors had

intact bladder

Long-term Outcomes After Bladder Preserving Combined Modality Therapy for Muscle-invasive Bladder Cancer: A Pooled Analysis of RTOG 8802, 8903, 9506, 9706, 9906, and 0233

Category 5 Years 10 Years

Overall Survival 57% 36%

Disease Specific Survival71% 65%

IJROBP 2012;84:S121

Radiation used as primary treatment for muscle invading bladder cancer

US 10%Scandinavia 25%UK > 50%

Muscle Invading Bladder Cancer


Surgery 43 – 50%Induction Chemo/Surgery 53 – 57%Conservation 48 – 68%

J Natl Compr Canc Netw 2013;11:952-960

A 10-year review of 458 patients undergoing radical radiotherapy or cystectomy

Munro NP, Sundaram SK, Weston PM, et al. Int J Radiat Oncol Biol Phys 2010;77(1):119–124.


radical cystectomy 24%radiation therapy 22%

Survival Comparisons T2-T4a

Reference Number 5Year Surv 10 Year Surv

Radical Cystectomy

Stein 633 48% 32%Dalbagni 181 36% 27%Grossman 307 50% 34%

Bladder Preservation

Rodel 326 45% 39%Efstathiou 348 52% 35%Shipley 123 49% na

Radiation plus Chemotherapy is Superior to Radiation Alone

+

Concurrent cisplatin and preoperative or definitive radiation. NCIC Clinical Trials group.

Coppin CM J Clin Oncol1996;14(11):2901–2907.

Treatment Pelvic RelapseChemo + Radiation 15/51 (29%)Radiation Alone 25/48 (52%)

5 Year Survival with Radiation for muscle invading bladder cancer

Radiation alone 34 – 39% Chemo-Radiation 51%

Bladder Preservation Trials

Therapy Complete Response 5 YearSurvival

Radiation 57% 47%Rad. + cisplatin 85% 69%Rad. + carboplatin 70% 57%

Cancer Control 2013;20:189

Palliative radiotherapy in the management of bladder carcinoma

Duchesne Int J Radiat Oncol Biol Phys 2000;47(2):379–388.

68% achieved symptomatic improvement (71% for 35 Gy, 64% for 21 Gy

treatment options for cancer of the bladder

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