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EAU 2018

EAU 2018: The Best Local Palliative Treatment for Inoperable Bladder Cancer Patients

Copenhagen, Denmark (UroToday.com) Dr. Van Oort presentated a talk discussing the best local palliative treatment for inoperable bladder cancer patients. Dr. Van Oort started by highlighting that 19.2% of people in the European Union are older than 65 years of age and, people that live until 65 years of age can expect to live 21.2 (females) and 17.9 (males) additional years. 

Data from the Dutch Cancer Registry (1989-2013) show that cancer specific and overall survival has not changed in the past 25 years when stratified by disease stage. Trends in treatment have also changed, stratified by age:

  • cT2-4N0M0, age <75 years: increasing rates of cystectomy and neoadjuvant therapy, stable rates of radiotherapy, and decreasing rates of patients not receiving definitive therapy
  • cT2-4N0M0, age ≥75 years: increasing rates of cystectomy and radiotherapy, and decreasing rates of patients not receiving definitive therapy
  • cT4b/N+/M+, age <75 years: increasing rates of cystectomy and neoadjuvant chemotherapy, stable rates of radiotherapy and chemotherapy alone, and decreasing rates of patients not receiving definitive therapy
  • cT4b/N+/M+, age ≥75 years: in 2013, nearly 60% still receive no therapy, ~20% receive radiotherapy, and very small proportion receive chemotherapy
It appears that age alone is keeping oncologists from treating patients according to Dr. Van Oort. In fact, the European Urology guidelines suggest that chronological age is of limited relevance, and that external beam radiotherapy should be considered when patients are unfit for cystectomy or a multimodal bladder sparing approach. A phase II trial assessing radical TURBT and three negative deep biopsies for selected patients with muscle invasive bladder cancer and 15 years of follow-up found that 5-, 10-, and 15-year CSS rates were 82%, 80%, and 77% [1]. During the first three years, 70% of patients progressed and 65% of patients recurred.

Dr. Van Oort notes that treatment options should be decided on with the patients using a shared-decision making platform. For example, an elderly individual with bladder cancer should first undergo a frailty assessment, then have a quality of life assessment/discussion, followed by appropriate patient participation in shared-decision making based on geriatric assessment/life expectancy assessment vs bladder cancer-specific survival. Subsequently, specific recommendations/decisions are based on all of the above factors and a finalized individualized bladder cancer treatment plan is made. 

Dr. Van Oort notes that after the shared-decision making process the best treatment option may indeed be palliative. Quoting Dame Cicely Saunders, founder of the hospice movement “You matter because you are you and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.” Palliative care intends to neither hasten or postpone death, but rather to reduce suffering. Early palliative care has been shown to prolong survival, but also to decrease depressive mood symptoms. 

Dr. Van Oort concluded with several key take home messages: (i) 20% of the total European population are considered elderly, (ii) elderly patients live ~20 additional years after reaching 65 years of age, (iii) the elderly population continues to grow, (iv) more elderly (30-60%) than younger patients (8-27%) do not get treatment of their invasive bladder cancer, and (v) there are treatment options for the elderly, including cystectomy, radiotherapy, multimodal treatment and radical TURBT. Regardless of the treatment option decided on, Dr. Van Oort cautions against using age as an argument not to treat the patient but to engage in a shared-decision making process with the patient. 


Presented by:  Inge M. Van Oort, MD,  Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands 

References:
1. Solsona E, Iborra I, Collado A, et al. Feasibility of radical transurethral resection as monotherapy for selected patients with muscle invasive bladder cancer. J Urol 2010;184(2):475-480.
redicting nodal involvement.

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, twitter: @zklaassen_md at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark