THE STATUS OF BLADDER. P. RESERVING THERAPEUTIC STRATEGIES IN THE MANAGEMENT OF PATIENTS WITH MUSCLE–INVASIVE BLADDER CANCER

Abstract

AbstractThe recommended treatment for medically fit patients with muscle–invading bladder cancer is usually radical cystectomy. However, transurethral resection of the tumor, partial cystectomy, irradiation and systemic chemotherapy are each effective in some patients. These latter treatments allow bladder preservation and cure as an alternative to radical cystectomy although when used unselectively the survival rates are inferior to those of radical cystectomy.The updated results of conservative surgery, radiation therapy and systemic chemotherapy as monotherapy, as well as strategies of combined modality treatment were reviewed. Based on this review many areas of consensus were reached which include:1. The primary goal of any 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. While no multi–modality therapeutic regimen has yet been shown to be clearly optimal with regard to local efficacy and minimizing toxicity, monotherapy for bladder preservation 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 significantly increase 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 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 must be performed to establish the role of optimal combined modality treatment for bladder preservation, but patient recruitment into 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. Further, urologists must be prepared to have their patients randomized into phase III protocols and investigators must not allow premature publication of findings.