Management Of Muscle-invasive Bladder Cancer Research Articles

Radical Cystectomy and the Multidisciplinary Management of Muscle-Invasive Bladder Cancer.

Radical Cystectomy and the Multidisciplinary Management of Muscle-Invasive Bladder Cancer.

Bladder Sparing Approaches for Muscle-Invasive Bladder Cancers.

Opinion statementOrgan preservation has been increasingly utilised in the management of muscle-invasive bladder cancer. Multiple bladder preservation options exist, although the approach of maximal TURBT performed along with chemoradiation is the most favoured. Phase III trials have shown superiority of chemoradiotherapy compared to radiotherapy alone. Concurrent chemoradiotherapy gives local control outcomes comparable to those of radical surgery, but seemingly more superior when considering quality of life. Bladder-preserving techniques represent an alternative for patients who are unfit for cystectomy or decline major surgical intervention; however, these patients will need lifelong rigorous surveillance. It is important to emphasise to the patients opting for organ preservation the need for lifelong bladder surveillance as risk of recurrence remains even years after radical chemoradiotherapy treatment. No randomised control trials have yet directly compared radical cystectomy with bladder-preserving chemoradiation, leaving the age-old question of superiority of one modality over another unanswered. Radical cystectomy and chemoradiation, however, must be seen as complimentary treatments rather than competing treatments. Meticulous patient selection is vital in treatment modality selection with the success of recent trials within the field of bladder preservation only being possible through this application of meticulous selection criteria compared to previous decades. A multidisciplinary approach with radiation oncologists, medical oncologists, and urologists is needed to closely monitor patients who undergo bladder preservation in order to optimise outcomes.

Exploring multidisciplinary practice patterns in the management of muscle invasive bladder cancer (MIBC) across the U.S. and Canada in 2015.

368 Background: Effective treatment of MIBC requires a multidisciplinary (multiD) approach including surgical, radiation, and chemotherapeutic modalities, which are further supported by pathology, radiology, nursing, social work, nutrition, pharmacy, and psychologic expertise. As surgical and bladder preservation approaches have not been directly compared, practice patterns are heterogeneous. Our primary objective was to catalogue the different styles of multiD approaches or lack thereof in the management of MIBC. Secondary objectives were to assess physician interest, capture examples of successful approaches, and describe barriers to implementation. Methods: We conducted an international online survey regarding the type of multiD approach and available resources used by clinicians managing MIBC. We collaborated with the Bladder Cancer Advocacy Network and the Genitourinary Medical Oncologists of Canada to reach a wide variety of academic and community practices. Results: Of the 101 clinicians surveyed, most practiced at NCI designated comprehensive cancer centers (46%) or Canadian academic institutions (29%). The median number of cases per month was 5 (0-40).Of the different multiD styles, sequential (separate) visits on different days was the most common (60%) followed by sequential same day (41%), concurrent (one visit with all providers, 23%), and none (5%). However, most preferred a sequential same day (44%) or concurrent (28%) approach. Although most academic practices had some form of multiD approach, reported barriers for implementing the preferred strategy were lack of clinic space (63%), funding (46%), staff (46%), and time (34%). The majority felt a multiD approach enriched their practice. Conclusions: Most surveyed practitioners at academic centers integrate a multiD strategy in the management of MIBC. The major barriers are not attitudinal but rather insufficient resources and time. Thus, most physicians employ a sequential rather than a concurrent approach. Future goals include developing strategies to overcome these obstacles and integrating these results with patient preferences to optimize the management of MIBC patients.

Management of muscle-invasive bladder cancer

Cancer that has invaded the detrusor muscle can be associated with a high degree of morbidity and mortality. Radical treatments are required, including cystectomy, radiotherapy and chemotherapy. These treatments can cause short-term and long-term consequences for patients. In this article the authors describe the current treatment approaches to muscle-invasive bladder cancer.

Management of muscle-invasive bladder cancer in the elderly.

The number of cases of muscle-invasive bladder cancer is increasing along with the age of the population. Management of muscle-invasive bladder cancer in the elderly is complex, requiring a multidisciplinary team approach and a comprehensive assessment of each individual patient. A geriatric assessment should be used to inform treatment decisions in elderly patients with bladder cancer. There is increasing evidence to support aggressive therapy in appropriate elderly patients, including radical cystectomy and neoadjuvant chemotherapy. Adjuvant chemotherapy also has a role in patients with high-risk disease after cystectomy. A bladder preservation approach with trimodality therapy is a well tolerated and effective alternative to cystectomy in appropriately selected patients. Treatment decisions should not be based on chronologic age alone and advanced age should not preclude aggressive or curative therapy. The recent molecular characterization of bladder cancer and several recent immunotherapy trials provide hope of a more targeted approach to treatment of bladder, potentially improving both effectiveness and tolerability of treatment regimens in the elderly.

Optimal management of muscle-invasive bladder cancer - a review.

Muscle-invasive bladder cancer is a complex disease requiring aggressive management. Patients are often older with comorbid conditions that impact treatment options. This review describes the available therapies for invasive urothelial carcinoma, including chemotherapy, radical extirpative surgery, and bladder-preserving strategies.

An Effective and Well Tolerated Strategy of Bladder Preservation Therapy in Cisplatin-Ineligible Patients With Muscle-Invasive Bladder Cancer

BackgroundThe purpose of this study was to determine the feasibility and clinical effectiveness of concurrent weekly carboplatin chemotherapy in conjunction with definite radiation with or without adjuvant chemotherapy in the treatment of muscle-invasive bladder cancer. Patients and MethodsBetween April 2010 and December 2013, 30 patients with muscle-invasive bladder cancer were evaluated retrospectively in this study. Concurrent chemoradiotherapy (CCRT) with weekly carboplatin was initiated. CCRT was followed by 2 courses of carboplatin and gemcitabine limited to patients with Eastern Cooperative Oncology Group performance status < 3 and age < 80 years. ResultsThirty patients were treated and all completed the CCRT protocol. Seven of 8 patients (88%) achieved a pathological complete response (pCR) with CCRT alone, and 18 of 22 patients (82%) treated with CCRT followed by adjuvant chemotherapy had a pCR. The median follow-up was 23.2 (range, 8.3-40.7) months. The median progression-free survival was 15.9 months for the CCRT group, and not sufficient to evaluate CCRT followed by adjuvant chemotherapy. The median overall survival with CCRT was 18.8 months, and had not yet been reached for CCRT with adjuvant chemotherapy. The protocol was well tolerated for adverse events. ConclusionOur study has shown that concomitant chemotherapy using weekly carboplatin in the management of muscle-invasive bladder cancer is feasible and well tolerated, even in older patients. Additional adjuvant chemotherapy with 2 cycles of carboplatin and gemcitabine should be encouraged in physically fit patients. These results provide a basis for randomized studies to compare this approach with conventional therapy for patients who wish to preserve the bladder.

Perioperative Strategies to Reduce Postoperative Complications After Radical Cystectomy

Radical cystectomy with creation of urinary diversion is the standard treatment for muscle-invasive urothelial carcinoma of the bladder. Despite advances in perioperative care, radical cystectomy is associated with significant morbidity. Reduction in perioperative morbidity and mortality remains a primary focus of bladder cancer outcome improvement. A number of evidence-based approaches to perioperative care have been proposed to reduce the overall burden of complications associated with radical cystectomy. Herein, we highlight and review recent and evolving evidence-based strategies to minimize the morbidity associated with surgical management of muscle-invasive bladder cancer.

Side effects of targeted therapies. Introduction.

The role of adjuvant chemotherapy remains poorly defined for the management of muscle-invasive bladder cancer (MIBC). The last meta-analysis evaluating adjuvant chemotherapy, conducted in 2005, had limited power to fully support its use.To update the current evidence of the benefit of postoperative adjuvant cisplatin-based chemotherapy compared with control (ie, surgery alone) in patients with MIBC.A comprehensive literature review was performed to identify all randomized controlled trials (RCTs) comparing adjuvant cisplatin-based chemotherapy with control for patients with MIBC. The search included the Medline, Embase, Cochrane Central Register of Controlled Trials databases, and abstracts from the American Society of Clinical Oncology meetings up to May 2013. An updated systematic review and meta-analysis was performed.A total of 945 patients included in nine RCTs (five previously analyzed, one updated, and three new) were examined. For overall survival, the pooled hazard ratio (HR) across all nine trials was 0.77 (95% confidence interval [CI], 0.59–0.99; p = 0.049). For disease-free survival, the pooled HR across seven trials reporting this outcome was 0.66 (95% CI, 0.45–0.91; p = 0.014). This disease-free survival benefit was more apparent among those with positive nodal involvement (p = 0.010).This updated and improved meta-analysis of randomized trials provides further evidence of an overall survival and disease-free survival benefit in patients with MIBC receiving adjuvant cisplatin-based chemotherapy after radical cystectomy.

Examining the management of muscle-invasive bladder cancer by medical oncologists in the United States

BackgroundNeoadjuvant chemotherapy (NACT) for the treatment of muscle-invasive bladder cancer (MIBC) remains underutilized in the United States despite evidence supporting its use. ObjectivesTo examine the perioperative chemotherapy management of patients with MIBC by medical oncologists (MedOncs) to move toward standardization of practice Participants and methodsA 26-question survey was emailed to 92 MedOncs belonging to the Bladder Cancer Advocacy Network or the American Society of Clinical Oncology for completion from May to October 2011 ResultsA total of 83 MedOncs completed the survey: 52% were based in academic centers. Most referrals were from urologists (79%). NACT for treatment of MIBC and high-grade upper-tract urothelial carcinoma is offered by 80% and 46% of respondents, respectively. Adjuvant chemotherapy for treatment of MIBC and upper-tract urothelial carcinoma is offered by 46% and 42% of respondents, respectively. NACT was not offered by 49%, 29%, and 35% of respondents if Eastern Cooperative Oncology Group performance status was 3 or greater, if patients had T2 lesions without lymphovascular invasion, and if the glomerular filtration rate was<50ml/min, respectively. Chemotherapy regimens included gemcitabine/cisplatin (90%), methotrexate/vinblastine/adriamycin/cisplatin (30%), dose-dense methotrexate, vinblastine, adriamycin, and cisplatin (20%), and gemcitabine/carboplatin (37%). ConclusionsMost MedOncs (79%) in this survey offer perioperative chemotherapy to all patients with MIBC. This increased use of NACT is higher than previously reported, suggesting an increase in the adoption of recommendations that follow best evidence.

Multimodal management of muscle-invasive bladder cancer

Bladder cancer is the most common malignancy of the urinary tract and the ninth most common malignancy in the world, with an estimated overall global 5-year prevalence of 1,110,265. In the United States, an estimated 74,690 new cases and 15,580 deaths from bladder cancer are expected in 2014. Urothelial (transitional cell) carcinoma is the predominant histologic type in the United States, accounting for 90% of all bladder cancers.

Endoscopic Gold Fiducial Marker Placement into the Bladder Wall to Optimize Radiotherapy Targeting for Bladder-Preserving Management of Muscle-Invasive Bladder Cancer: Feasibility and Initial Outcomes

Background and PurposeBladder radiotherapy is a management option for carefully selected patients with muscle-invasive bladder cancer. However, the inability to visualize the tumor site during treatment and normal bladder movement limits targeting accuracy and increases collateral radiation. A means to accurately and reliably target the bladder during radiotherapy is needed.Materials and MethodsEighteen consecutive patients with muscle-invasive bladder cancer (T1–T4) elected bladder-preserving treatment with maximal transurethral resection (TUR), radiation and concurrent chemotherapy. All underwent endoscopic placement of 24-K gold fiducial markers modified with micro-tines (70 [2.9×0.9 mm.]; 19 [2.1×0.7 mm.) into healthy submucosa 5-10 mm. from the resection margin, using custom-made coaxial needles. Marker migration was assessed for with intra-op bladder-filling cystogram and measurement of distance between markers. Set-up error and marker retention through completion of radiotherapy was confirmed by on-table portal imaging.ResultsBetween 1/2007 and 7/2012, a total of 89 markers (3–5 per tumor site) were placed into 18 patients of mean age 73.6 years. Two patients elected cystectomy before starting treatment; 16/18 completed chemo-radiotherapy. All (100%) markers were visible with all on-table (portal, cone-beam CT), fluoroscopy, plain-film, and CT-scan imaging. In two patients, 1 of 4 markers placed at the tumor site fell-out (voided) during the second half of radiotherapy. All other markers (80/82, 98%) were present through the end of radio-therapy. No intraoperative (e.g. uncontrolled bleeding, collateral injury) or post-operative complications (e.g. stone formation, urinary tract infection, post-TUR hematuria >48 hours) occurred. Use of micro-tined fiducial tumor-site markers afforded a 2 to 6-fold reduction in bladder-area targeted with high-dose radiation.DiscussionPlacement of the micro-tined fiducial markers into the bladder was feasible and associated with excellent retention-rate and no complications. All markers were well-visualized during radiotherapy with all imaging modalities. Bladder fiducial markers improve targeting accuracy, and may increase treatment efficacy and reduce morbidity from collateral radiation.

Radical cystectomy versus trimodality bladder-preserving therapy for muscle-invasive bladder cancer among elderly (80-84 years old) patients.

340 Background: Management of muscle-invasive bladder cancer (MIBC) in elderly patients is issue of vital importance. The aim of the present study was to compare the oncological outcome of radical cystectomy to trimodality bladder preservation therapy. Methods: Between 1996 and 2013, we treated consecutive 419 patients with MIBC. Of these, we identified 44 patients with MIBC (cT2-4aN0M0) aged 80-84 years. We retrospectively reviewed the clinical charts of these patients. All patients received maximally safe transurethral resection of the bladder tumor before definitive therapy. The patients were categorized according to the treatment options into 2 cohorts; radical cystectomy cohort (RCx, n = 22), or radiotherapy with chemotherapy cohort (Trimodality, n = 22). All patients in trimodality cohort received at least 2 courses of gemcitabine plus carboplatin chemotherapy. Each patient was evaluated every 3-6 months by blood test, urine cytology, and computed tomography. Overall survival (OS), progression free survival (PFS) was estimated by Kaplan-Meier method. Multivariate analysis was used to identify independent factors to predict OS or PFS. Results: There were no significant differences in patient backgrounds between the groups, except for ECOG performance status (ECOG-PS), Charlson comorbidity index (CCI) and eligibility for cisplatin. The mean ECOG-PS, CCI and the number of cisplatin-unfit patients were significant higher in trimodality cohort (p = 0.001, p = 0.034, and p = 0.003, respectively). There were no significant differences in OS and PFS between the groups. On multivariate analysis, ECOG-PS &gt;1 was the independent prognostic factors for OS and PFS. Conclusions: Trimodality bladder preservation therapy for MIBC in elderly patients is comparable to those who received radical cystectomy. For patients with MIBC who are non-cystectomy candidates, or select patients who are motivated to keep their native bladders, trimodality bladder preservation therapy should recognized as an effective alternative to radical cystectomy, and be considered.

1444 ACCESS TO CARE INFLUENCES ADHERENCE TO GUIDELINES FOR MANAGEMENT OF MUSCLE-INVASIVE BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Invasive (I)1 Apr 20131444 ACCESS TO CARE INFLUENCES ADHERENCE TO GUIDELINES FOR MANAGEMENT OF MUSCLE-INVASIVE BLADDER CANCER C.J. Stimson, Sanjay G. Patel, Harras B. Zaid, Sam S. Chang, Matthew J. Resnick, Samuel D. Kaffenberger, Michael S. Cookson, and Daniel A. Barocas C.J. StimsonC.J. Stimson Nashville, TN More articles by this author , Sanjay G. PatelSanjay G. Patel Nashville, TN More articles by this author , Harras B. ZaidHarras B. Zaid Nashville, TN More articles by this author , Sam S. ChangSam S. Chang Nashville, TN More articles by this author , Matthew J. ResnickMatthew J. Resnick Nashville, TN More articles by this author , Samuel D. KaffenbergerSamuel D. Kaffenberger Nashville, TN More articles by this author , Michael S. CooksonMichael S. Cookson Nashville, TN More articles by this author , and Daniel A. BarocasDaniel A. Barocas Nashville, TN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2798AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES National Comprehensive Cancer Network (NCCN) guidelines recommend radical cystectomy (RC) with pelvic lymph node dissection (PLND) as the standard of care for patients with muscle-invasive bladder cancer (MIBC). Using the National Cancer Database (NCDB), we sought to determine how health care access impacts adherence to this guideline. METHODS The NCDB captures approximately 70% of all cancer diagnoses from 1400 accredited hospitals in the US. We analyzed patients with stage cT2 or cT3/cN0/cM0 urothelial cell carcinoma, diagnosed from 1998-2010. We examined the relationship between clinical and socioeconomic variables and use of RC/PLND versus non-RC/PLND, which encompassed any other management (transurethral resection of bladder tumor [TURBT], radiation, chemotherapy, partial cystectomy, or combinations thereof) that did not include RC/PLND. We performed both univariate chi-squared and t-test analyses and multivariate logistic regression analysis to determine whether access-related factors influence use of RC/PLND. RESULTS 29115 patients met our inclusion criteria, 6413 (22.0%) had RC/PLND, while 667 (2.3%) had neoadjuvant chemotherapy with RC/PLND. On univariate analysis there were statistically significant associations between RC/PLND and age, race, year of diagnosis, insurance status, income, metro/urban/rural, distance from hospital, geographic location, Charlson Comorbidity Index, clinical stage, and tumor grade (p < 0.05 for each). These associations were preserved on multivariate analysis (Table). Stratifying by geographic region and altering the outcome to TURBT versus RC/PLND did not substantially change the results. An exploratory model with neoadjuvant chemotherapy plus RC/PLND as the outcome showed similar associations but with wide confidence intervals due to the small number of patients who received this combination. CONCLUSIONS A minority (22.0%) of patients with cT2 or cT3 BC were treated with RC/PLND. In addition to expected associations between clinical factors and treatment, factors influencing access to care, including race, income, insurance status, and distance from hospital, were associated with variation in adherence to treatment guidelines for MIBC. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e591-e592 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information C.J. Stimson Nashville, TN More articles by this author Sanjay G. Patel Nashville, TN More articles by this author Harras B. Zaid Nashville, TN More articles by this author Sam S. Chang Nashville, TN More articles by this author Matthew J. Resnick Nashville, TN More articles by this author Samuel D. Kaffenberger Nashville, TN More articles by this author Michael S. Cookson Nashville, TN More articles by this author Daniel A. Barocas Nashville, TN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Achieving the achievable in muscle-invasive bladder cancer

Patient outcomes reported from clinical trials and case series from centres of excellence define the benchmark for what is achievable among patients with muscle-invasive bladder cancer (MIBC). However, because patients, medical care and health systems can be very different in routine clinical practice there is often a gap between efficacy (i.e., results observed in trials) and effectiveness (i.e., results observed in the general population).1,2 Population-based studies are important to identify gaps in care and areas for improvement so that clinicians and patients might move towards “achieving the achievable.”3 Multiple population-based studies and a meta-analysis have consistently demonstrated an inverse relationship between hospital cystectomy volume and postoperative mortality.4–8 However critical questions remain unanswered including: what factors are responsible for the observed volume effect?; how much of the observed effect relates to hospital volume versus individual surgeon volume?; and how should volume be defined, classified and analyzed? Furthermore, beyond operative mortality and complications there is considerably less literature describing the relationship between cystectomy volume and long-term survival.9 In the paper by Bianchi and colleagues published in this issue of CUAJ, the authors have evaluated the impact of hospital academic affiliation on short term radical cystectomy outcomes.10 Using records from the Health Care Utilization Project Nationwide Inpatient Sample the authors explore postoperative complications and mortality across hospitals in the United States. The unadjusted results suggest greater complication rates, length of stay (LOS), and post-operative mortality in patients who have surgery at non-academic hospitals. However, in the multivariate analysis the there is no difference in LOS and post-operative mortality and a statistically significant but clinically modest increase in complications. A more fundamental question is how to disentangle the relationship between hospital volume, academic status, and outcome? While most previous studies have analyzed volume as either a continuous variable or a categorical variable using tertiles/quartiles, Bianchi and colleagues dichotomize annual hospital caseload as greater than 15 or less than 15 cystectomies per year.10 The cut-point is very high relative to other studies where “high volume” hospitals are usually defined as those that perform >5 to 10 cystectomies per year.4–8 In dichotomizing this outcome and using such a high threshold, Bianchi and colleagues are left with only 12% (n = 1515) of their study population in the high volume group and all of these cases had surgery at academic hospitals. Accordingly it is very likely that any potential volume effect has been lost in the statistics. The authors suggest that patients treated at academic hospitals are slightly younger, have less comorbidity, and are more likely to have private health insurance.10 Despite adjusted analyses there remains the potential for unmeasured confounding. Higher volume hospitals might have higher volume surgeons with better surgical technique, improved perioperative care and more multidisciplinary co-management. It is less straightforward to conceptualize or measure how academic status in itself might be associated with outcome independent of hospital volume. This highlights the importance in any volume-outcomes research to sequentially control for covariates that might partially explain any observed association between volume and outcome. This is critical because it can provide insight into the reasons why higher volume hospitals (or academic hospitals) have better outcomes and thereby creates a model to improve outcomes at low- and medium-volume centres. The alternative is to consolidate all care at high-volume hospitals which may not be feasible, practical, or desirable and needs to be balanced against the very real risk of reduced access to care. This issue has been nicely explored by Elting and colleagues in their study of all cystectomy cases in Texas during 1999–2001.5 Although unadjusted postoperative mortality was lower in high-volume hospitals they discovered that much of the association was explained by differences in the nurse-to-patient ratio such that good outcomes could also be achieved in lower volume hospitals with higher staffing ratios. Management of MIBC is complex and best managed by a multidisciplinary team. In addition to maximizing the effectiveness of cystectomy in routine clinical practice, efforts are required to improve uptake of perioperative chemotherapy and ensure that patients who are not candidates for cystectomy are considered for radical radiotherapy which also offers the chance of long term survival. It is imperative to understand how quality and processes of care can be maximized to close the efficacy-effectiveness gap and improve patient outcomes.

Bladder conservation for muscle-invasive bladder cancer

In the UK alone, approximately 10,000 patients are diagnosed with bladder cancer each year. Of these, muscle-invasive bladder cancer stage T2 or T3 accounts for 10–15%, with the remainder being non-muscle-invasive tumors, dealt with by local intravesical treatment. This group of patients are often older, the median age at presentation being 65–70 years and since this is a smoking-associated cancer there are often significant comorbidities. Transitional cell carcinoma is the most common histological type and comprises >90% of bladder cancers. Other cell types include squamous cell carcinoma, adenocarcinoma, small-cell carcinoma, sarcoma, carcinosarcoma, lymphoma and melanoma. In bladder cancer, the most important prognostic factors are stage and grade. Cystectomy, radiotherapy and chemotherapy all have a role in the management of bladder cancer. In many centers across the world, the standard management of muscle-invasive bladder cancer, stage T2 and T3, is radical cystectomy and pelvic lymphadenectomy. There is now increasing evidence that modern nonsurgical approaches using chemoradiation achieve results at least as good as those with surgery and enable bladder preservation in the majority of patients. Optimal chemoradiation schedules and the role of radiosensitizers remain important areas of research to optimize the bladder-preserving approach. Ultimately, a prospective randomized trial is needed to compare modern state-of-the-art surgery with chemoradiation to provide high-level evidence on which informed patient choices can be made.

Contemporary management of muscle-invasive bladder cancer

The current standard treatment for muscle-invasive nonmetastatic bladder cancer is neoadjuvant platinum-based chemotherapy followed by radical cystectomy. However, neoadjuvant chemotherapy is not widely accepted even with level 1 evidence. Adjuvant chemotherapy should be discussed if patients have not received neoadjuvant chemotherapy before surgery and have high-risk pathologic features. Although not considered standard of care, bladder-sparing therapy can be considered for highly selected patients and for those medically unfit for surgery. Even though there are no level 1 data, the treatment outcomes for highly select patients given bladder-sparing therapy appear promising, with many patients retaining a functional bladder. Personalized chemotherapy is currently being actively pursued to target the underlying molecular changes and tailor to individual needs.

Robotic-assisted radical cystectomy: current technique and outcomes

Robotic-assisted radical cystectomy continues to evolve as a surgical option in the management of muscle-invasive bladder cancer. Current oncologic outcomes appear comparable in the short-term with open radical cystectomy. Long-term follow-up, however, remains lacking for this emerging technique. Modern robotic technology allows a comparable extent of pelvic lymph node dissection as open surgery, a previous criticism of the procedure. Complications compare very favorably to open surgery in comparative series, and blood loss and transfusion rates are routinely lower. Length of stay has been shortened in some series, though not uniformly. Finally, robotic assistance can increase the cost of radical cystectomy.

The neoadjuvant management of muscle-invasive bladder cancer (MIBC) in Canada: A national survey of urologists.

303 Background: There is level 1 evidence and a 5% absolute survival benefit supporting the use of cisplatin-based neoadjuvant chemotherapy (NC) for the management of MIBC. Despite this, it is well known that the majority of eligible patients undergoing cystectomy do not receive NC. We previously surveyed medical oncologists and found that the majority will offer NC to MIBC patients depending on stage, renal function, performance status (PS), and comorbidities. However, the number of MIBC patients being referred for consideration of NC by urologists remains low. The aim of this followup survey to urologists was to better understand their approach to MIBC, and referral patterns for NC. Methods: A survey consisting of 24 questions was administered to Canadian urologists belonging to the Canadian Urologic Oncology Group. Respondents completed the survey and mailed/faxed back their responses. The survey was similar to, but not identical to the previous medical oncology survey. Results: Of the 25 respondents, 21/25 (84%) were academic, &gt;90% were in full-time practice, and 72% were practising for &gt;10 yrs. Most (84%) treated over 20 bladder cancer cases annually. Overall, 22/25 (80%) will offer a NC approach if appropriate. In 2009, 9/24 (38%) sent &gt;6 referrals for NC; 2/24 (25%) sent 5-6 referrals, 6/24 (20%) sent 3-4 referrals, and 5/24 (8%) sent 1-2 referrals. NC was offered as standard of care or to downsize tumors. Initial staging included cystoscopy, CT chest/abdo/pelvis and bone scan. Key factors cited for not offering NC were: T2a disease, GFR &lt;40ml/min, age &gt;85 or PS 3 or 4. Average time from NC to cystectomy was 4-6 wks. Conclusions: The majority of academic urologists in Canada will refer MIBC patients for NC except those with T2a disease, poor renal function, age &gt;85 or poor PS. Non-academic urologists are underrepresented in this survey, and may represent the group facing the greatest challenges in offering NC, due to issues such as access to medical oncology, or lack of local expertise in managing MIBC. Targeting non-academic urologists, and encouraging consultation with a medical oncologist for all patients with MIBC, may lead to increased utilization of NC, and better outcomes in this disease.

Examining the management of muscle-invasive bladder cancer (MIBC) by medical oncologists (MO).

298 Background: Neoadjuvant chemotherapy (NC) for the treatment of MIBC remains underutilized in the United States despite evidence supporting its use. The aim of this project is to examine the current management of MIBC by MO to move towards standardization of practice. Methods: An electronic 26 question survey was emailed to 92 MO belonging to the Bladder Cancer Advocacy Network or the American Society of Clinical Oncology, and posted on the US Oncology portal for 8 wks. The study was approved by the Office of Management and Budget (0925-0046). Percentages are based on the fraction that responded to a given question. Results: Of the 83 respondents: 48% were non-academic. 51% were general oncologists and 45% focused on GU malignancies. The majority of MIBC referrals came from urologists (79%). Initial CT staging with abd/pelvis was required by 88%, CT chest by only 72% and PET by 21%. NC is offered by 79% of MO to all MIBC pts and by 45% to all pts with high grade upper tract urothelial carcinoma. Adjuvant chemotherapy (AC) was offered by 46% to all MIBC pts and by 41% to pts with upper tract disease. NC was not offered if ECOG performance status (PS) was &gt;3 (49%), in T2 disease without lymphovascular invasion (29%), or with GFR of &lt;50 ml/min (35%). Chemotherapy regimens used for NC included gemcitabine/cisplatin (90%); methotrexate/vinblastine/adriamycin/cisplatin (MVAC) (30%), dose dense MVAC (20%); gemcitabine/carboplatin (36%); single-agent gemcitabine (10%), other regimens described include carboplatin/paclitaxel and ifosfamide/doxorubicin/gemcitabine. Response to NC was assessed by CT abd/pelvis (82%), CT chest (39%), cystoscopy (30%) and PET (12%). Pts with pathologic residual disease (&gt;pT2 or positive LN) after NC were generally observed (74%). Conclusions: The majority of MO do offer perioperative chemotherapy for MIBC pts with a trend towards increased use of NC over AC, which follows best evidence. The main reason for not offering perioperative chemotherapy was poor PS. The majority offer cisplatin-based combination therapy by preference. Increasing the rate of referrals of MIBC pts to MO, will result in more pts receiving perioperative cisplatin-based chemotherapy and may lead to better outcomes in this disease.