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Chemotherapy for muscle-invasive bladder cancer treated with definitive radiotherapy: persisting uncertainties

Nature Clinical Practice Oncology volume 5, pages 444–454 (2008)Cite this article

Abstract

Radical cystectomy for invasive bladder cancer remains the standard of care in many parts of the world, including North America and many parts of Europe; however, a large body of international experience from single institutions and cooperative groups indicates satisfactory results with bladder-sparing approaches in appropriately selected patients. Overall, selective bladder preservation with trimodality therapy, consisting of transurethral resection of the bladder tumor, radiation, and chemotherapy, can achieve complete response rates of 70%, long-term survival rates of 40–50%, and survival rates with an intact bladder of 30–45%. Neoadjuvant chemotherapy followed by radiotherapy might provide up to 5% additional long-term absolute survival benefit compared with radiotherapy alone, although the studies to support this are not appropriately powered. Concomitant chemoradiation provides high response rates and disease control, although the level of evidence for this approach and the follow-up data are even less robust than those for neoadjuvant chemotherapy. Although direct comparison of surgically based and radiotherapy-based approaches would be very useful, it is highly unlikely that such a trial could ever be completed among the patients treated by the clinicians who routinely deal with invasive bladder cancer.

Key Points

  • Definitive radiotherapy has been used most often in the British Commonwealth and Europe for patients with muscle-invasive bladder cancer who have sought bladder preservation; in North America this approach has usually been applied to only those deemed unfit to undergo cystectomy

  • Over the past 30 years, most studies of radiotherapy for invasive bladder cancer have shown only a 20–40% long-term survival rate, although in many instances, dosing and fractionation may have been inadequate by current standards

  • Phase II clinical trials and retrospective studies have shown that chemoradiation can produce high rates of complete remission, bladder preservation and local disease control; however, data from phase III trials comparing the outcomes of this approach with those of surgery are lacking

  • Careful patient selection for chemoradiation (on the basis of known prognostic criteria) may yield a high cure rate with bladder preservation; early, salvage cystectomy should be considered when early cystoscopic assessment reveals failure of radiotherapy

  • Neoadjuvant chemotherapy before definitive radiation, rather than concurrent chemoradiation, has shown variable outcomes, with one major phase III trial demonstrating a small but insignificant survival benefit

  • It is not known whether radiotherapy-based regimens and cystectomy provide identical long-term survival rates, although in most major centers in North America it is believed that the best cure rates are achieved by combined-modality regimens that incorporate cytotoxic chemotherapy and surgery

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Author notes

  1. D Raghavan is the Chair of the Cancer Division, and Director of the Taussig Cancer Center, at the Cleveland Clinic and Lerner College of Medicine, Cleveland, OH, USA.

Authors and Affiliations

  1. TK Choueiri is a genitourinary oncologist in the Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MS,

    Toni K Choueiri & Derek Raghavan

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Correspondence to Derek Raghavan.

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Choueiri, T., Raghavan, D. Chemotherapy for muscle-invasive bladder cancer treated with definitive radiotherapy: persisting uncertainties. Nat Rev Clin Oncol 5, 444–454 (2008). https://doi.org/10.1038/ncponc1159

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