NEW ORLEANS, LA USA (UroToday.com) - In this lecture, Dr. Peter Black provided an overview of the current state of surgical management for muscle-invasive bladder cancer (MIBC). He focused on four different topics:
- Ensuring all patients eligible for curative therapy receive it.
Several studies have shown that only half of the patients with MIBC in the US receive curative intent local therapy. He discussed that this appeared to be an age-dependent phenomenon as a significantly larger
proportion of patients over 70-years-old were undertreated. Guidelines for management of geriatric patients with prostate and kidney cancer have been published by the Society of Geriatric Oncology, but Dr. Black pointed out that none exist for bladder cancer. He emphasized the importance of the use of appropriate geriatric assessment tools to ensure that patients are being treated based on their functional age as opposed to their chronological age. He also emphasized that urologists need to better embrace multimodality therapy, particularly in the elderly population, to ensure that more patients eligible for curative intent are actually receiving it. - Debating whether an extended pelvic lymph node dissection should be the standard of care.
Dr. Black outlined the two current prospective studies examining whether an oncologic benefit exists for performing an extended pelvic lymph node dissection in MIBC. The LEA trial out of Germany has completed patient accrual, and is powered to detect a 15% progression-free survival (PFS) difference at 5 years. The SWOG S1101 trial has accrued 2/3 of its targeted patient number and is powered to detect a 10% disease-free survival difference at 3 years. Until the results of these trials are available, definitive statements regarding whether standard or extended lymph node dissection should be the standard must be withheld. Dr. Black commented that there was a possibility that there might be a clear advantage seen with extended lymph node dissection, which does not meet the lofty goals of the two trials. He stated that this may result in continued debate on the topic. - Data comparing robotic to open radical cystectomy.
Dr. Black discussed that multiple, prospective, randomized trials comparing open to robotic cystectomy have been published. He focused on the trial out of Memorial Sloan Kettering Cancer Center that found no difference in complication rates between open and robotic radical cystectomy. This study also found no difference in lymph-node yield, positive-margin rates, hospital length of stay, or patient quality of life at 3 and 6 months. Robotic cystectomy did require over 2 hours more operative time however, which resulted in an increased cost. Dr. Black questioned whether intracorporeal diversion might make a difference in outcomes, but stated that further studies are necessary. He discussed that attention should be paid to whether or not the U pouch used by some in robotic cystectomy results in different functional outcomes in comparison to the Studer neobladder, given the decreased folding used for the U pouch. Finally he reviewed a study by Nguyen et al. that reported similar recurrence rates between open and robotic radical cystectomy, but noted higher rates of extrapelvic lymph node recurrence and peritoneal carcinomatosis in the robotic surgery group. The rates of extrapelvic nodal recurrence and peritoneal carcinomatosis were derived using only those who recurred as the denominator however, and if one looked at patients with extrapelvic lymph node recurrence and peritoneal carcinomatosis in the context of all patients receiving either open or robotic surgery, these rates were low and appeared more equivalent between the two techniques. - Increasing rates of neoadjuvant chemotherapy administration.
While neoadjuvant chemotherapy use has increased in MIBC, it still falls around 50% at best. He pointed out that this number was derived from academic centers and that it is likely significantly lower in the community setting. Better predictors of responders to chemotherapy may help to increase rates of administration and decrease overtreatment. Several studies have demonstrated that bladder cancer subtypes exist, and that the p53 subtype has been shown to be associated with resistance to MVAC and gemcitabine/cisplatin. In contrast, patients with ERCC2 mutations have demonstrated sensitivity to cisplatin-based chemotherapy. Validation of predictors of chemotherapy response is essential, and Dr. Black pointed out that the Coxen clinical trial is currently underway to address this.
Presented by Peter Black, MD at the American Urological Association (AUA) Annual Meeting - May 15 - 19, 2015 - New Orleans, LA USA
Vancouver Prostate Center, University of British Columbia, Canada
Reported by Timothy Ito, MD, medical writer for UroToday.com