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Optimal candidates for bladder preservation vs radical cystectomy


“I would say that patients who have a very poor bladder function to start with would be a better candidate for radical cystectomy,” says Sophia C. Kamran, MD.

In this video, Sophia C. Kamran, MD, discusses optimal candidates for bladder-preserving treatments. Kamran is a radiation oncologist at the Massachusetts General Hospital Cancer Center and Assistant Professor of Radiation Oncology at Harvard Medical School, Boston, Massachusetts.


Who are the optimal candidates for the strategy of bladder preservation?

When it comes to the standard therapies for patients that have muscle-invasive bladder cancer, we think about radical cystectomy or bladder preservation. Sometimes, there's not a perfect patient that can fit into both. Sometimes, we do get lucky and we do have patients that are perfect candidates for either, and then it really is their decision. We deal with real-life patients, and there are things that we have to take into account; we have to think about the patient as a whole. We obviously want to make sure that we optimize their oncologic treatment, but we always are thinking about quality of life as well. I would say a patient who is an excellent candidate for bladder-sparing therapy has a very good performance status and a small tumor, typically that is in one area that's easily resectable on transurethral resection of the bladder tumor. Ideally, we'd want a unifocal tumor, not something that's multifocal (meaning in multiple spots all over the bladder). Those can just be very difficult to resect. That candidate that I just described is actually probably an excellent candidate for either radical cystectomy or bladder preservation. Patients who might be pushed more toward bladder preservation are those who have comorbidities that make them high surgical risk, so then we would want to avoid surgery, and they would be an excellent candidate for bladder preservation. And then there are patients who come with a strong desire to preserve their bladder, of course, they'd be a great candidate, if they have all the other features. I would say patients where we would be favoring surgery are patients who start off with poor bladder function. We want to save a bladder worth saving, so if patients have a lot of bladder symptoms, we know that chemo radiation is going to just make that worse, and so they're going to probably live with a worse overall bladder function going forward, and that can really affect their quality of life. So I would say that patients who have very poor bladder function to start with would be a better candidate for radical cystectomy. There are other factors: patients who have had prior pelvic radiation would be better candidates for radical cystectomy. If they have inflammatory bowel disease, that's another category where we would want to avoid radiation. Then there's the final category of patients who are really not great candidates for either, but for whom we'd probably favor bladder preservation. If they have poor renal function or they have a multifocal tumor, they're not going to do great with either treatment most likely or their oncologic outcomes might not be as high. And then of course, if they have a poor performance status, we would favor bladder preservation in those patients as well. We're thinking about all these things when we evaluate our patients, and we absolutely are always considering what would give the highest oncologic outcome, which is the desire of the treatment, but then always taking into account their quality of life going forward.

This transcript was edited for clarity.

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