SUO 2018: Role of Trimodality and Comparison with Cystectomy in Muscle Invasive Bladder Cancer

Phoenix, Arizona (UroToday.com) The ideal candidate for bladder preservation in patients with muscle invasive urothelial carcinoma is often debated, as is the overall of efficacy of bladder preservation with trimodal therapy compared to radical cystectomy. As part of the Bladder Cancer session at the 2018 annual meeting of the Society of Urologic Oncology, Dr. Alexandre Zlotta from the University of Toronto provided his thoughts on this controversial topic.

Dr. Zlotta began his discussion by describing the multidisciplinary clinic at the University of Toronto that was founded in 2008. The clinic consists of urologic oncologists, medical oncologists, radiation oncologists, and genitourinary pathologists. The goal of establishing this clinic was to allow a second opinion of complex urologic malignancy treatment in British Columbia. He acknowledges that when experts of varying disciplines work together and have an interdisciplinary discussion, patients can be treated in an optimal fashion.

Over the time since the multidisciplinary clinic has existed, they have defined several criteria that they feel makes a patient an ideal candidate for bladder preservation, including tumors <7cm, unifocal tumors, absences of carcinoma-in-situ (CIS), absence of bilateral hydronephrosis, and good bladder function. In Toronto, candidates for bladder preservation undergo trimodal therapy including complete TURBT, chemotherapy, and external beam radiotherapy.

Zlotta and his group retrospectively reviewed their patients from 2008 to 2013 who underwent their bladder preservation protocol and used propensity-matching to compare this cohort to other contemporary patients undergoing radical cystectomy. They compared the overall survival (OS) and disease-specific survival (DSS) using Cox proportional hazards modeling and competing risk analysis. They identified 112 patients with muscle-invasive bladder cancer during this timeframe who were treated with either trimodal therapy or radical cystectomy, with a median follow-up for 4.51 years. They found that the disease-specific survival for the trimodal therapy group was 76.6% versus 73.2% for the radical cystectomy group (p = 0.49). 10.7% of patients in the bladder preservation cohort eventually required salvage cystectomy. There were no significant differences in overall survival, nor disease specific survival. He acknowledged that local recurrence can be an issue in both groups, with 38% of cystectomy patients experiencing recurrence, versus 59% of bladder preservation patients. He noted, however, that many of the patients with isolated recurrences after trimodal therapy can be treated with endoscopic resection with or without intravesical BCG immunotherapy.

Dr. Zlotta finished the discussion by concluding that he feels that bladder cancer patients are optimally managed by a multidisciplinary team of experts. By working together, patients benefit from the highest possibility of disease control or cure. He also noted that in selected patients with muscle-invasive bladder cancer, trimodal therapy can yield survival outcomes similar to matched patients treated with radical cystectomy. His talk brings up the importance of counseling patients about alternative treatment options so that they can make an informed decision regarding their care.

Presented By:  Alexandre Zlotta, MD, PhD, University of Toronto

Written by: Brian Kadow, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Philadelphia, PA, at the 19th Annual Meeting of the Society of Urologic Oncology (SUO), November 28-30, 2018 – Phoenix, Arizona
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