NEW ORLEANS, LA USA (UroToday.com) - The topic of today’s "Crossfire: Controversies in Urology" was muscle-invasive bladder cancer and it featured a debate on the issue of whether bladder sparing for invasive cancer is cancer sparing or not. Drs. Ashish Kamat and Gary Steinberg supported the pro side of the argument, while Drs. William Shipley and Bernard Bochner presented the cons.
Dr. Shipley started the session with a slide taken from Gray et al. (Eur Urol 2012) demonstrating the unmet need for treatment of MIBC among the elderly. While rates of cystectomy approach 70% in patients < 50-60 years old, these rates drop precipitously to 20% among octogenarians. This may be that many patients are not suitable for RC. Meanwhile, combined modality therapy (CMT) has been approved by NCCN, EAU, and UK guidelines. Prospective clinical trials by SWOG, RTOG, BC2001, and the Italian oncologists have demonstrated similar 5-year OS between the 2 treatment modalities on the order of 45-54%.
Mak et al. published a pooled analysis of RTOG protocols with DSS curves similar for patients < 75 and >75, suggesting that younger and older patients fare well long term. One caveat he presented is that complete TURBT is an important factor in CMT success: Efstathiou et al. (Eur Urol 2012) showed that 5-year OS was 57% in complete TURBT vs 43% in incomplete resections. 22% of patients with complete TURBT underwent cystectomy in the immediate (non-CR) or salvage setting, vs 42% of patients in whom TURBT was incomplete. Clinical T-stage also proved to be an important factor. 5-year DSS was 74% among T2 patients vs 53% among those with T3-T4 disease.
Dr. Shipley reiterated that the key to success in CMT is patient selection. Those who have the highest success are patients who have complete resection, solitary cT2 tumors, no hydronephrosis, and no variant histology (i.e., urothelial only). He concluded that the weight of evidence-based medicine shows that chemo + RT + TURBT is a smart, patient friendly approach to the well-selected patient.
Dr. Kamat countered this with 4 facts: 1) Bladder cancer is lethal, and cystectomy + neoadjuvant chemotherapy offers the best chance of cure; 2) Bladder cancer is an expensive disease, and that after XRT, life-long surveillance plus further interventions may be needed; 3) Bladder cancer is a heterogenous disease that requires personalized treatment. Pathology is the best tool currently in our arsenal, and this is not offered by CMT; 4) Cure + QOL = a win-win situation.
In support of his first fact, he presented data from the 2012 Cochrane review on XRT vs RC. In an analysis of 439 patients randomized to RC vs XRT, ORs for all trials favored surgery over XRT. MD Anderson’s low-risk cohort of MIBC showed a 5-year DSS of 81%; the same statistic published by Hautmann et al. (Eur Urol 2012) for all-comers cT2-cT4a Nx was 71%.
Regarding surveillance strategies, a risk-adapted follow-up is used for pT1 or less with annual imaging. Meanwhile, RT involves imaging, cystoscopy, and q3-6 month follow-up. Of all cancers, bladder cancer has the highest lifetime treatment cost per patient at $230,000.
Current clinical staging is inaccurate, and pathology remains our best tool for tailored risk assessment. Gray et al. (Int J Radiat Oncol Biol Phys 2014) showed that 41.9% of patients were upstaged on final pathology, compared to only 5.9% who were downstaged. Dickstein et al. (UIJ 2013) showed that CT scanning was only able to accurately identify 35.4% of patients with pT3 disease.
Dr. Bachner stated that patient selection remains the key to success. Goals can be achieved with less than radical surgery in a well-selected patient. Grey et al. (Eur Urol 2013) demonstrated that while surgery in underused in elderly patients, non-radical approaches are similarly underused.
Dr. Steinberg rounded out the session with a review of QOL issues in bladder-sparing patients. Urinary complaints include incontinence, irritative symptoms, and hematuria; sexual complaints include erectile dysfunction and dysorgasmia; bowel complaints include diarrhea, incontinence, tenesmus, and hematochezia. He presented the MGH data on UDS and QOL findings in long-term survivors of CMT, and points out that 25% had abnormal UDS findings and 21% had poor compliance. Moreover, 15% had urgency, 19% had incontinence, 11% wore pads, and 6% had complaints regarding flow.
The session was concluded by Dr. Studer, who reported that in selected patients, CMT can be successful, and that results cannot necessarily be compared with surgical cohorts. Best results are seen when CMT is performed after complete TURBTs. Finally, he identified that the best way to preserve bladder function is to avoid unnecessary radical treatment.
Debater - Pro: Ashish M. Kamat, MD, MBBS, FACS
Debater - Pro: Gary D. Steinberg, MD
Debater - Con: Bernard H. Bochner, MD
Debater - Con: William U. Shipley, MD
Moderated by Urs E. Studer, MD at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA
Reported by Nikhil Waingankar, MD, medical writer for UroToday.com