Treatment Options for Cancer of the Bladder

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Understanding the treatment options for bladder cancer including surgery, radiation and chemotherapy

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Treatment Options for Cancer of the Bladder

  1. 1. The Treatment of Cancer of the Bladder www.aboutcancer.com
  2. 2. Bladder Cancer Understanding bladder cancer Treatment options of bladder cancer (surgery, radiation, chemotherapy) Radiation techniques and side effects
  3. 3. NCCN.org
  4. 4. www.nccn.org
  5. 5. Treatment of Bladder Cancer Early Stage: Surgery (TUR or transurethral resection of the bladder followed by intravesical chemotherapy (i.e. Mitomycin) or immunotherapy (BCG) Muscle Invading Cancer: Surgery (total or partial cystectomy) may be preceded by chemotherapy or followed by chemotherapy and/ or radiation depending on the stage. If the patient is not a candidate for surgery then chemotherapy or radiation may be alternatives Advanced: chemotherapy or radiation
  6. 6. cystoscope bladderurethra prostate Cystoscopy
  7. 7. TURB Trans Urethral Resection
  8. 8. Chemotherapy into the Bladder
  9. 9. Treatment of Bladder Cancer Early Stage: Surgery (TUR or trans urethral resection of the bladder followed by intravesical chemotherapy (i.e. Mitomycin) or immunotherapy (BCG) Muscle Invading Cancer: Surgery (total or partial cystectomy) may be preceded by chemotherapy or followed by chemotherapy and/ or radiation depending on the stage. If the patient is not a candidate for surgery then chemotherapy or radiation may be alternatives Advanced: chemotherapy or radiation
  10. 10. Surgery
  11. 11. Surgery Total Cystectomy Partial Cystectomy
  12. 12. Surgery Results Large single-center experiences report a 45%-66% 5- year overall survival after radical cystectomy. In recent studies, the mortality rate after radical cystectomy is less than or equal to 3%, and the complication rate varies between 25% and 57% in the first 30 days after surgery. With surgery alone, 20%-30% of patients with pT2 disease, 40%-60% of patients with pT3 disease, and 70%-90% of patients with pT4 disease will develop distant metastases or local recurrences and die of their cancer; consequently, 5-year survival rates after radical cystectomy in contemporary series average 66% for pT2 disease, 35% for pT3 disease, and 27% for pT4 disease.
  13. 13. Surgery Results Stage Relapse Survival pT2 20-30% 66% pT3 40-60% 35% pT4 70-90% 27%
  14. 14. Treatment of Bladder Cancer Early Stage: Surgery (TUR or trans urethral resection of the bladder followed by intravesical chemotherapy (i.e. Mitomycin) or immunotherapy (BCG) Muscle Invading Cancer: Surgery (total or partial cystectomy) may be preceded by chemotherapy or followed by chemotherapy and/ or radiation depending on the stage. If the patient is not a candidate for surgery then chemotherapy or radiation may be alternatives Advanced: chemotherapy or radiation
  15. 15. Radiation Therapy
  16. 16. Radiation for Bladder Cancer • Post Operative radiation for high risk cancers • Radiation plus chemotherapy to cure cancers and avoid removing the bladder (bladder preservation protocols) • Radiation alone or with chemotherapy for patients who are not candidates for major surgery • For metastatic cancer
  17. 17. PostOperative Radiation International Journal of Radiation Oncology • Biology • Physics, Vol. 45, Issue 3, p221–222, 1999 Status at 5 Years Cystectomy Cystectomy + 50Gy Pelvic Control 78% 88% Cancer Specific Survival 40% 62%
  18. 18. PostOperative Radiation International Journal of Radiation Oncology • Biology • Physics, Vol. 45, Issue 3, p221–222, 1999 Status at 5 Years Cystectomy Cystectomy + 50Gy Pelvic Control 78% 88% Cancer Specific Survival 40% 62%
  19. 19. NCCN Guidelines 2014 ? Role for PostOp Radiation
  20. 20. After a Partial Cystectomy Consider adjuvant Radiation (category 2B) or Chemotherapy (category 2B) based on pathology report showing high risk features (pT3-4, or positive nodes or positive margins or high-grade) if no neoadjuvant was given
  21. 21. Radiation for Bladder Cancer • Post Operative radiation for high risk cancers • Radiation plus chemotherapy to cure cancers and avoid removing the bladder (bladder preservation protocols) • Radiation alone or with chemotherapy for patients who are not candidates for major surgery • For metastatic cancer
  22. 22. NCCN Guidelines 2014 for T2 • Radical Cystectomy (+/- neoadjuvant chemotherapy) Category 1 • Partial Cystectomy (highly selected) +/- chemotherapy • Bladder preservation protocol : Category 2B • If not suitable for major surgery then TURBT or chemoradiation or chemotherapy alone
  23. 23. Bladder Preservation Protocol • Maximal TURB • Chemoradiation to 40-45Gy • Repeat Cystoscopy • If no disease complete chemoradiation go 60-66Gy • If residual tumor then cystectomy
  24. 24. Long term survival following radical cystectomy for TCC of the bladder—comparison between primary and radical cystectomy. Addla SK, Naidu P, Maddineni SB, et al. J Urol 2009;181(4):(abstr 1754). Treatment 5 Year Survival Primary Cystectomy 45.5% Salvage Cystectomy 42%
  25. 25. Combined-modality treatment and selective organ preservation in invasive bladder cancer Rödel C, Grabenbauer GG, Kuhn R, et al. J Clin Oncol 2002;20(14):3061–3071. 5- and 10-year survivals of 51% and 31% and included patients deemed inoperable.
  26. 26. Chemoradiation trials of Bladder Cancer from the RTOG • Complete Response: 59 – 81% • 80% of Long Term Survivors had intact bladder
  27. 27. Long-term Outcomes After Bladder Preserving Combined Modality Therapy for Muscle- invasive Bladder Cancer: A Pooled Analysis of RTOG 8802, 8903, 9506, 9706, 9906, and 0233 Category 5 Years 10 Years Overall Survival 57% 36% Disease Specific Survival 71% 65% IJROBP 2012;84:S121
  28. 28. Radiation used as primary treatment for muscle invading bladder cancer US 10% Scandinavia 25% UK > 50%
  29. 29. Muscle Invading Bladder Cancer Treatment 5 Year Survival Surgery 43 – 50% Induction Chemo/Surgery 53 – 57% Conservation 48 – 68% J Natl Compr Canc Netw 2013;11:952-960
  30. 30. A 10-year review of 458 patients undergoing radical radiotherapy or cystectomy Munro NP, Sundaram SK, Weston PM, et al. Int J Radiat Oncol Biol Phys 2010;77(1):119–124. Treatment 10 Year Survival radical cystectomy 24% radiation therapy 22%
  31. 31. Survival Comparisons T2-T4a Reference Number 5Year Surv 10 Year Surv Radical Cystectomy Stein 633 48% 32% Dalbagni 181 36% 27% Grossman 307 50% 34% Bladder Preservation Rodel 326 45% 39% Efstathiou 348 52% 35% Shipley 123 49% na
  32. 32. Radiation plus Chemotherapy is Superior to Radiation Alone +
  33. 33. Concurrent cisplatin and preoperative or definitive radiation. NCIC Clinical Trials group. Coppin CM J Clin Oncol1996;14(11):2901–2907. Treatment Pelvic Relapse Chemo + Radiation 15/51 (29%) Radiation Alone 25/48 (52%)
  34. 34. 5 Year Survival with Radiation for muscle invading bladder cancer Radiation alone 34 – 39% Chemo-Radiation 51%
  35. 35. Bladder Preservation Trials Therapy Complete Response 5 Year Survival Radiation 57% 47% Rad. + cisplatin 85% 69% Rad. + carboplatin 70% 57% Cancer Control 2013;20:189
  36. 36. Radiation for Bladder Cancer • Post Operative radiation for high risk cancers • Radiation plus chemotherapy to cure cancers and avoid removing the bladder (bladder preservation protocols) • Radiation alone or with chemotherapy for patients who are not candidates for major surgery • For metastatic cancer
  37. 37. Palliative radiotherapy in the management of bladder carcinoma Duchesne Int J Radiat Oncol Biol Phys 2000;47(2):379–388. 68% achieved symptomatic improvement (71% for 35 Gy, 64% for 21 Gy

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