Bladder-Conserving Therapy for Invasive Bladder Cancer Using Transurethral Surgery, Chemotherapy, and Radiation Therapy with Patient Selection by Initial Treatment Response

Abstract

The Fourth International Consensus Meeting on Bladder Cancer provided updated results of conservative surgery, radiation therapy, and systemic chemotherapy, each as monotherapy, as well as strategies of combined modality treatment with two or three of these modalities as reviewed by a panel of nine urologic oncologists (K. Koiso, W.U. Shipley, S. Keuppen, L. Baert, R.R. Hall, M. Hudson, S. Khoury, Y. Kubota, and H. Van Poppel). Based on this review, ten areas of consensus were reached: 1. The primary goal of bladder preservation treatment for a patient with muscle-invading bladder cancer is survival; bladder preservation in the interest of quality of life is a secondary objective. 2. Only a small proportion of carefully selected patients may be cured by transurethral surgery alone or by partial cystectomy alone. 3. Radiation therapy is currently the standard bladder-preserving therapy against which all other bladder-preserving methods must be compared. 4. Systemic chemotherapy as monotherapy is inadequate and cannot be recommended. 5. The addition of cisplatin-containing systemic chemotherapy to radiation therapy or conservative surgery appears to improve local control. Whilst no multimodality therapeutic regimen has yet been shown to be clearly optimal with regard to local efficacy and minimization of toxicity, monontherapy for bladder-preserving treatment is probably not desirable as a routine approach. 6. Deferring the patient from immediate cystectomy does not appear to compromise survival nor does the addition of primary systemic chemotherapy appear to increase significantly the morbidity of cystectomy or radiotherapy. 7. All patients treated by bladder-preserving therapy must return to the urologist for regular cystoscopic follow-up so that additional therapy may be started at the earliest opportunity, if relapse occurs. 8. Bladder substitution will always be second best and is suboptimal compared with a normally functioning disease-free bladder. 9. If alternatives to cystectomy are not considered, little progress will be made in the treatment of muscle-invading bladder cancer. 10. Randomized phase III trials will have to be performed to establish the role of optimal combined modality treatment for bladder preservation but patient recruitment to such trials may prove difficult unless urologists are prepared to open their minds to the possibility that cystectomy may not be the best treatment for all patients with muscle-invading bladder cancer.