TREATING PATIENTS WITH INVASIVE BLADDER CANCER WITHOUT SURGICAL REMOVAL OF THE BLADDER
What is combined-modality therapy?
For all the sites in the body where cancer may arise, modern therapies are increasingly looking towards eradicating the cancer while at the same time preserving the affected organ (bladder, breast, voice box) and giving the patient the best possible functional outcome and thus quality of life. This is usually achieved by the combination of lesser surgery, with radiation, and chemotherapy, all in lower doses than if used alone. Modern Combined-Modality Therapy (CMT) for bladder cancer follows just that pattern. It begins with an aggressive resection of the visible tumor then following it with Radiation Therapy (RT) given together with chemotherapy. The latter makes the remaining tumor more sensitive to the radiation. When patients are well selected for this approach it can offer equal cure rates to treating with a cystectomy while still preserving a functioning bladder. This approach is favored for patients who are strongly motivated to maintain their bladder or in patients who have so many other medical problems that a radical cystectomy is simply not a safe option.
Who is suitable for bladder preserving therapy by CMT and how are they to be followed?
Many factors play into the determining which patients with Muscle Invasive Bladder Cancer (MIBC) are suitable for CMT. Ideally, these patients would have cancers with the usual urothelial histology (a small proportion have different appearance down the microscope). They would have clinical stage T2 to T3a disease, and the absence of hydronephrosis (the partial obstruction by the tumor of the ureter that transmits the urine from the kidney to the bladder). In addition, the best candidates are those with tumors small enough to have been visibly completely resected at TURBT. If a visibly complete resection is performed then the radiation and chemotherapy have only to mop up the remaining microscopic cells, a much easier prospect.
Following treatment patients must be followed closely with cystoscopy surveillance to detect any cancer recurrence or development of a new primary tumor in the bladder or elsewhere within the urogenital tract (ureters, bladder, urethra).
A minority of patients will have cancers that do not respond completely or who develop an invasive recurrence after CMT. For them, a “salvage” cystectomy is recommended and a significant number can be cured in this fashion.
The subsequent quality of life of patients after treatment
The primary objective of CMT is to cure while preserving the bladder. Bladder preservation only has merit, however, if the preserved bladder and other pelvic organs function at acceptable levels after treatment. Patients should expect some degree of temporary urinary irritative symptoms and bowel symptoms during treatment but this is to be distinguished from serious irreversible complications that the physicians now strive to avoid. The patient’s baseline urinary function before treatment is an important consideration, since patients with very poor baseline urinary function may not have a “bladder worth sparing.”
Multiple national and international medical agencies have now developed consensus guidelines and all recommend the use of combined-modality therapy (CMT) for many presentations of muscle-invasive bladder cancer. The approaches presented here are consistent with these guidelines. In addition, several patient advocacy groups serve as good resources for providers and patients. For example, the Bladder Cancer Advocacy Network is the largest community of bladder cancer survivors, and medical and research professionals and advocates that offers education and support to patients and providers and funding to advance research for bladder cancer.
Click here to read our Bladder Preservation with Combined-Modality Therapy (CMT) | An Expert Explanation (PDF) for the full and more in-depth information by Dr. William Shipley, member of our Scientific Advisory Board.
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