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

1. The Treatment of
Cancer of the Bladder
www.aboutcancer.com

2. Bladder Cancer
Understanding bladder
cancer
Treatment options of
bladder cancer (surgery,
radiation, chemotherapy)
Radiation techniques and
side effects

3. NCCN.org

4. www.nccn.org

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. cystoscope
bladderurethra
prostate
Cystoscopy

7. TURB
Trans Urethral Resection

8. Chemotherapy into the
Bladder

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. Surgery

11. Surgery
Total Cystectomy Partial Cystectomy

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. Surgery Results
Stage Relapse Survival
pT2 20-30% 66%
pT3 40-60% 35%
pT4 70-90% 27%

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. Radiation Therapy

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. 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. 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. NCCN Guidelines 2014
? Role for PostOp Radiation

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. 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. 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. 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. 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. 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. Chemoradiation trials of Bladder
Cancer from the RTOG
• Complete Response: 59 – 81%
• 80% of Long Term Survivors had
intact bladder

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. Radiation used as primary
treatment for muscle invading
bladder cancer
US 10%
Scandinavia 25%
UK > 50%

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. 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. 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. Radiation plus Chemotherapy is
Superior to Radiation Alone
+

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. 5 Year Survival with Radiation for
muscle invading bladder cancer
Radiation alone 34 – 39%
Chemo-Radiation 51%

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. 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. 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