Outcomes of Tri-Modality Bladder-Sparing Therapy for Muscle-Invasive Bladder Cancer

Abstract

Although radical cystectomy is considered the standard of care for muscle-invasive bladder cancer (MIBC) in North America, the resultant urinary diversion or neobladder construction is a morbid and life-altering outcome for patients. Recent data has shown comparable survival results for bladder-sparing tri-modality therapy (TMT) involving complete transurethral resection of bladder tumor (TURBT), radiotherapy (RT), and chemotherapy. As there remains paucity in data to change clinical practice, we conducted a retrospective analysis of patients in our institution to better define clinical outcomes of TMT in the setting of MIBC. A retrospective chart review was performed of adult bladder cancer patients assessed by a multi-disciplinary team consisting of uro-oncologists, medical oncologists, and radiation oncologists. Included patients were diagnosed with MIBC (T2-T4) in the past 6 years and underwent curative intent treatment with maximal TURBT followed by concurrent chemoradiation (≥50 Gy; platinum-based agent or fluorouracil + mitomycin). Patients who underwent radical RT alone following TURBT were also included. Clinical and treatment data were summarized including resection status, pathological features, response to treatment, and salvage cystectomy rates. Overall survival (OS) and disease-specific survival (DSS) were estimated using the Kaplan-Meier method. Of 116 included patients, 54 underwent TMT and 62 underwent radical RT alone following TURBT. The median age at diagnosis was 79 years and the median follow-up was 1.9 years. Clinical T-stage was T2 in 84% of patients and maximum TURBT was performed in 72% of patients. Complete response rates in those receiving TMT and RT alone were 70% and 50%, respectively. The overall local recurrence rate was 12%. The local recurrence rates in the TMT and RT only groups were 11% and 13%, respectively. In the TMT cohort, 4% of patients had grade 3 or higher late toxicity and 2% of patients underwent salvage cystectomy. For TMT patients, median OS and DSS were 57.2 and 28.1 months, respectively. Two-year OS and DSS were 74.5% and 51.5%, respectively. Based on our data, TMT remains a safe and effective alternative to radical cystectomy and should be offered to appropriately selected patients with MIBC. This multi-disciplinary approach appears to yield similar survival outcomes with minimal toxicity, while avoiding the morbidity of surgical intervention especially in older patients. Confirmation in larger patient cohorts with longer follow-up is required.