Treatment strategies using transurethral surgery, chemotherapy, and radiation therapy with selection that safely allows bladder conservation for invasive bladder cancer

Abstract

Combined modality therapy with the goal of effecting cure and achieving organ preservation has become the standard oncological approach in many malignancies. Although radical cystectomy has been considered the standard treatment for invasive carcinoma of the bladder, equivalent results have been achieved using combined modality treatment in selected patients, particularly those with T2 and T3a disease without obstructed ureters. Effective combined modality treatment consists of three treatment modalities: (1) transurethral resection of the bladder tumor (TURBT), followed by concurrent (2) chemotherapy, and (3) radiation. Following induction therapy, histologic response is evaluated by cystoscopy and biopsy. Clinical complete responders continue with concurrent chemotherapy and irradiation. Those patients not achieving a clinical complete response are advised to undergo cystectomy. Individually the local monotherapies of radiation, TURBT, or systemic chemotherapy each achieve a local control rate of 20% to 40%. When they are combined, complete response rates of 70-80% are achieved and 85% of these will remain free of invasive recurrence in the bladder. Bladder preservation trials using combined modality treatment approaches with selection for organ conservation by response to initial treatment report an overall 5-year survival rate of approximately 50%, and they have achieved a 40% to 45% 5-year survival rate with the bladder intact. Modern multi-modality bladder preservation approaches offer survival rates similar to radical cystectomy, for patients of similar clinical stage and age, and an improved quality of life by allowing a majority of patients to retain their own fully functional bladder. Bladder conservation therapy may be offered to selected patients with bladder cancer as one alternative to radical cystectomy, and its use should be by experienced multi-modality teams of urologic oncologists.