How do bladder Ca treatments compare in terms of survival?

While they are different approaches to treating the same disease, there are no notable differences in overall survival, disease-specific survival, and progression-free survival between radical cystectomy and bladder-preserving combined modality treatment for muscle-invasive bladder cancer, according to a meta-analysis published in the International Journal of Radiation Oncology • Biology • Physics (2017; 97:1002-20).

Higher rates of early major complications from cystectomy in this analysis of 12,380 patients provide compelling evidence that radiation therapy might be as good as surgery for many muscle-invasive bladder cancer patients, according to senior author Dharam Kaushik, MD. 

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“Urologists are the primary point of contact for patients with bladder cancer. When it comes down to having a pragmatic and genuine discussion regarding various treatment options for muscle-invasive bladder cancer, more knowledge about the treatment modalities is in the best interest of the patient. Radical cystectomy remains the preferred option for the majority of patients, but this study opens the door to greater evaluation of radiation therapy as a beneficial alternative. The decision must be made on a case-by-case basis,” said Dr. Kaushik, of The University of Texas Health Science Center (now called UT Health San Antonio) and the UT Health Cancer Center, San Antonio.

Dr. Kaushik and colleagues reviewed 19 randomized, controlled trials and prospective and retrospective studies comparing radical cystectomy with combined modality treatment, which is maximal transurethral resection of the bladder tumor and external-beam radiation therapy with concurrent chemotherapy. They evaluated survival rates and treatment-related complications by conducting meta-analyses of eight eligible studies, representing 9,554 subjects.

Next: No significant differences in overall survival and disease-specific survival at 5 and 10 years

They found no significant differences in overall survival and disease-specific survival at 5 and 10 years. In both cases, results favored combined modality treatment at 5 years and radical cystectomy at 10 years. The difference in progression-free survival at 10 years was statistically insignificant, but favored combined modality treatment. There were no studies that examined progression-free survival at 5 years’ post-treatment.

And while minor complication rates between the treatment options were similar, early major complications were more common among those treated with radical cystectomy.

The traditional paradigm for treatment of muscle-invasive bladder cancer is built on basic assumptions that radical cystectomy is a superior approach and combined modality treatment should be reserved for patients who are not surgical candidates, including those with extensive comorbidities and/or poor performance status, according to Dr. Kaushik.

Read: NMIBC guideline compliance remains low

The take-home for urologists, he said, is not only the lack of difference in survival rates between radical cystectomy and combined modality treatment for these patients, but also that urologists should consider prompt salvage surgery for disease recurrence in the setting of failed radiation therapy.

“Given the potential benefits of combined modality treatment, relative to radical cystectomy, clinical prediction of non-response to combined modality treatment would be of interest. These are the patients who can be selected early on for radical cystectomy. If predictive factors, such as pathology, genomic markers could be identified, patients might then be selected for the treatment most likely to benefit them. This may maximize overall cure rates and minimizing poor outcomes. Therefore, further clinical trials and translational research are required to identify optimal candidates for combined modality treatment,” Dr. Kaushik said.

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