Radical cystectomy (RC) is one of the most important treatments for bladder cancer. However, for many years, patients undergoing RC have not seen a more dramatic improvement in prognosis. In recent years, there has been a glimmer of hope for RC patients due to optimal treatment of high-risk stage T1 bladder cancer, chemotherapy in the perioperative period, and the use of robotics.
A concise review of research advances in RC and adjuvant/neoadjuvant chemotherapy in 2015 was presented by Prof. Witjes from the Netherlands and published in the recent NatureReviewsUrology.
Thesis 1: When to perform RC and which procedure is better?
In patients with non-muscle invasive bladder cancer (NMIBC), the question of which patients require early RC rather than electrodesiccation and bladder irrigation is a major problem for urologists.
It has been shown that those who progress from NMIBC to muscle-invasive bladder cancer (MIBC) have a tumor-specific mortality rate (CSM) twice as high as those who have MIBC at the time of initial diagnosis. Therefore, early identification of high-risk patients in NMIBC will be the next research priority in urology.
A retrospective analysis this year summarized the many factors that affect the prognosis of patients with T1NMIBC. It was found that the depth of cancer infiltration in the submucosa is an important indicator of disease progression and CSM.
In addition, the presence of carcinoma in situ, pre-existing lymphovascular infiltration, failure to use BCG, larger tumors, and older age were all suggestive of a worse prognosis. This result enlightens: is it possible to perform RC treatment early in patients who possess high-risk prognostic factors?
Assuming the patient has decided to undergo RC, the question arises whether to go with the traditional gold standard – open radical cystectomy (ORC) – or the emerging robotic-assisted radical cystectomy (RARC)?Two important articles in 2015 addressed this point.
Prof. Novara et al. systematically evaluated both procedures and found that although RARC had a longer operative time of 1 to 2 hours than ORC, blood loss was less, hospital days were 1 to 1.5 days shorter, and there were fewer low-grade complications than ORC.However, due to the poor quality of the literature included in this systematic evaluation, Prof. Witjes concluded that the level of evidence obtained from this literature was also low.
The results of a similar RCT conducted by Prof. Bochner et al. were more convincing. In that study, 60 patients underwent RARC and 58 patients were given ORC. there was no difference in complications between patients who underwent the two procedures at 90 days postoperatively, but blood loss was less in the RARC group than in the ORC. However, the cost of the RARC procedure itself was higher, which somewhat reduced the advantages of this procedure.
Based on these findings, Prof. Witjes pointed out that RARC may be able to surpass ORC, leaving aside the economic factors, but he also emphasized that the clinical experience and surgical skill of a surgeon is the key to the real benefit of both RARC and ORC.
Topic 2: Use and efficacy of adjuvant/neoadjuvant chemotherapy in patients receiving RC To minimize delays, urologists usually prefer RC to neoadjuvant chemotherapy. However, according to Prof. Reardon et al, there was a 40% increase in the use of chemotherapy in the perioperative period between 2006 and 2010, with a predominance of neoadjuvant chemotherapy.
According to Prof. Svatek et al, neoadjuvant chemotherapy can benefit high-risk MIBC patients (T≥3 or N+) who already have RC, with a 5-year survival rate of 32.8%. As to which neoadjuvant chemotherapy regimen is superior, some studies suggest that there is no difference between MAVC (methotrexate, vincristine, adriamycin and cisplatin) and GC (gemcitabine and cisplatin) regimens.
An article published by Professor Sternberg et al. compared the survival of two groups with adjuvant chemotherapy immediately after RC (141 cases) and delayed adjuvant chemotherapy (143 cases). After 5.2 to 8.7 years of follow-up, the 5-year progression-free (PFS) rate was significantly better in the immediate adjuvant chemotherapy group than in the delayed group (47.6% versus 31.8%). The study also found that the incidence of toxic side effects such as myelosuppression was also higher in the delayed group. This is consistent with current guidelines that suggest that early adjuvant chemotherapy improves patient prognosis.
In conclusion, Professor Witjes concluded that every small step forward in research this year on RC and perioperative chemotherapy is a big step forward for the field of bladder cancer. We also look forward to more new breakthroughs for bladder cancer patients this time next year.