With the improvement of people’s demand for quality of life after tumor treatment, radical treatment with organ preservation has become increasingly important in the treatment of tumors. This has become one of the hot spots of research in the treatment of invasive bladder cancer. In China, the radiation-based comprehensive treatment model for bladder cancer is not yet widely used, but the palliative role of radiation therapy for advanced bladder cancer or bladder cancer with systemic metastases is self-evident.
The efficacy of applying a single treatment to preserve the bladder for invasive bladder cancer is not satisfactory with either TURBT, radiotherapy alone or chemotherapy (Table 15-3) (12). If radical cystectomy is used, the 5-year survival rate can reach 68% and the 10-year survival rate 66%, but at the cost of losing the bladder (13). The available data suggest that the use of radiation-based combination therapy for this group of patients not only preserves the bladder, but also achieves a 5-year survival rate of 40% to 60% after treatment, which is very close to the level of radical surgery, with the benefit of preserving the bladder, improving quality of life, and the opportunity for salvage surgery even if the tumor recurs.
Table 15-3 Efficacy of single treatment with bladder preservation for invasive bladder cancer
Treatment
Number of study groups
Number of cases
Local control rate
Transurethral resection of tumor
2
331
20 %
Radiotherapy alone
5
949
41%
Chemotherapy alone
1
27
19%
The common features of this treatment are: (1) TURBT is performed first to maximize the resection of the tumor to clarify the stage; (2) concurrent radiotherapy is used, and the chemotherapy regimen is usually a combination of cisplatin (DDP) based regimen, or 5-FU, or Adriamycin; (3) radiotherapy is followed by cystoscopy to evaluate the efficacy, and if the treatment is unsuccessful, the treatment is then changed to Radical cystectomy. The difference is that in the United States, cystoscopy is performed to assess the efficacy of radiotherapy up to 40 Gy, whereas in the United Kingdom and Germany, the efficacy is assessed after radiotherapy up to the radical dose (Figure 15-2).
The results of two groups of patients treated with concurrent radiotherapy for bladder cancer were reported by the University of Birmingham research group in 2001 and 2004, with 31 and 41 cases, respectively, and a total radiotherapy dose of 55 Gy/20 times, with a 1-year survival rate of 68% and a 5-year survival rate of 36%. German scholars reported the use of simultaneous chemoradiotherapy after TURBT, with chemotherapy administered on days 1 and 5 and radiotherapy using first large field irradiation of the whole pelvis to 50.4 Gy (conventional irradiation) followed by local whole bladder dosing to 59.6 Gy, resulting in an overall 5-year survival rate of 65% in 49 patients and bladder preservation in 54% of patients. The US RTOG summarized the results of a total of 415 patients with invasive bladder cancer treated with concurrent chemoradiotherapy over the past 15 years, with a complete efficiency rate of about 70% and a 5-year bladder preservation survival rate of 50%. Massachusetts General Hospital treated 190 patients with T2 to T4a bladder cancer from 1986 to 1997, with an overall 5-year survival rate of 54%, a 10-year survival rate of 36%, and a 5-year survival rate of 45% with bladder preservation, including 50% for those with T2 and 34% for those with T3 to T4a (Table 15-4).
Flow chart of bladder preservation for invasive bladder cancer by American and European scholars
Table 15-4 Comparison of treatment outcomes between cystectomy and bladder preservation
Study hospital and treatment method
Stage
Number of cases
5-year survival rate (%)
10-year survival rate (%)
Cystectomy
American Cancer Society (2001)
T2-T4a
633
48
32
New York Memorial Hospital, USA (2001)
T2-T4a
181
36
27
Comprehensive treatment with bladder preservation
German Study Group (2002)
T2-T4
326
45
29
Massachusetts General Hospital (2001)
T2-T4a
190
54
36
RTOG (USA) (1998)
T2-T4
123
49
—
In a bladder-preserving comprehensive treatment modality, the accurate and complete performance of TURBT is crucial for the success of this modality. All tumors visible cystoscopically should be removed to the extent possible, and a more accurate pathologic staging should be obtained, and the principles of the first TURBT must still be followed in the second TURBT performed thereafter to assess efficacy. In the follow-up of patients who have achieved complete remission at the end of all treatments, TURBT can still be performed if isolated superficial lesions are found, thus preserving the bladder as much as possible.
There are currently two strategies for the administration of concurrent chemotherapy, the first DDP every 3 weeks at 70 mg/m2 and the other using DDP as a sensitizer at 25 mg/m2, d1 to d5 and d29 to d33. Due to renal insufficiency in some patients with bladder cancer, DDP is not suitable and similar efficacy can be achieved by switching to 5-Fu and MMC or to gemcitabine.