Toxicities and Survival of Elderly Patients With Muscle-Invasive Bladder Cancer Treated With Definitive Bladder Preservation Therapy

Abstract

Elderly bladder cancer patients with significant comorbidities are often not recommended for aggressive therapy. The purpose of this retrospective review is to identify toxicities and outcomes of elderly patients with significant comorbidities who received definitive bladder preservation therapy for muscle-invasive bladder cancer (MIBC). Between 2004 and 2012, 20 patients with non-metastatic MIBC were identified to undergo maximal transurethral resection of bladder tumor (TURBT) followed by definitive 3D conformal radiation therapy. Nineteen patients (95%) received concurrent chemoradiation therapy (CRT) while 1 patient was treated with radiation therapy alone. 13 of 19 patients treated with CRT received paclitaxel alone, 1 received paclitaxel and trastuzumab, 1 received gemcitabine, and 4 received cisplatin or carboplatin. Toxicities were assessed using Common Terminology Criteria for Adverse Events v4.0. Twenty patients with a median age of 79 years (range, 58-90 years) received a median dose of 63 Gy (range, 39.6-66.6 Gy). Seventeen patients (85%) were able to complete therapy and 4 (20%) were admitted at some point during radiation therapy, 2 for infection, 1 for hematuria and urinary retention, and 1 for increased urinary frequency and pain. No patients developed grade III gastrointestinal toxicity during or within 1 month of treatment, whereas 2 (10%) developed grade III anemia and 1 died of renal failure (grade 5 genitourinary toxicity). A total of 6 patients (30%) went on to develop grade III or higher genitourinary toxicity, including the patient who died of renal failure during treatment, and 4 (20%) developed grade III anemia. At the end of treatment, 16 patients underwent cystoscopy and 12 (75%) were shown to have achieved a complete response. Of the 4 patients with residual disease, 1 underwent radical cystectomy for salvage. Three patients went on to develop local failure. The median follow-up at the time of analysis was 25 months. The 2-year local failure-free survival was 31.3% and the 2-year progression-free survival was 33.3%. The 3-year overall survival was 37.5%. Karnofsky Performance Score (KPS) was an important predictor of survival. In patients with KPS ≤70, the 3-year OS was 17% compared to 50% in patients with KPS >70 (p = 0.016). The majority of MIBC patients with significant comorbidities were able to tolerate definitive radiation therapy concurrent with weekly paclitaxel alone. However, clinical outcomes appear inferior to the results of multicenter RTOG trials which report 3-year OS between 61-86% (RTOG 9506, RTOG 9706) in patients who were candidates for cystectomy. The poor outcomes of this small cohort of elderly patients might be related to their significant comorbidities and poor performance status.