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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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  • The department of cancer surgery deals with all kind of cancer surgeries including Radical surgeries, Complex reconstructions, Organ preservation & Surgeries by minimal invasive techniques. The department has world class infrastructure and well equipped with modular operation theater backed by good ICU and postoperative recovery unit. The department is supported by high end radiology & pathology services. The department also deals with Cancer awareness & Cancer screening programmes. http://www.primushospital.com
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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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