BOSTONA combination of transurethral resection (TUR) and radiochemotherapy with cisplatin(Drug information on cisplatin) (Platinol) and fluorouracil(Drug information on fluorouracil) (5-FU) produced the most promising results in a German study of bladder-sparing protocols for patients with invasive bladder cancer.
Thomas Brunner, MD, presented the study at the 42nd Annual Meeting of the American Society for Therapeutic Radiology and Oncology (ASTRO).
Researchers in the Department of Radiation Oncology, Universität Erlangen-Nürnberg, Erlangen, Germany, evaluated prognostic factors in 400 patients with invasive bladder cancer who received various combinations of combined-modality therapy from 1982 to 1999.
The goal was to identify predictors of which patients would most benefit from transurethral resection followed by radiotherapy with or without concomitant platinum-based chemotherapy.
The patients received 54 to 59.4 Gy of radiation to the bladder and 45 to 50 Gy to the regional lymph nodes and either no chemotherapy (137 patients) or chemotherapy (263 patients) during the first and fifth weeks of radiotherapy. Chemotherapy consisted of carboplatin(Drug information on carboplatin) (Paraplatin) (97 patients), cisplatin (127 patients), or cisplatin/5-FU (44 patients).
Dr. Brunner reported that the group as a whole had a 5-year disease-specific survival rate of 52%, with 80% of the survivors maintaining their bladder. The best results, a 5-year disease-specific survival rate of 77%, was achieved by the patients whose chemotherapy regimen included cisplatin and 5-FU.
"Patients who receive platinum-based chemoradiation do better," Dr. Brunner said, "and chemoradiation is better than radiotherapy alone."
Another significant outcome, he said, was a metastasis-free survival rate of 75% after 5 years for patients with residual invasive disease who had cystectomy. "That means that salvage cystectomy really has a curative intent," he said.
The study showed that the presence of tumor-associated carcinoma in situ (CIS) and multifocality of the tumor were not associated with poorer disease-specific survival. Dr. Brunner reported, however, that "patients who had multifocal tumors had a significantly higher incidence of invasive relapse than those with unifocal tumors."
Five-year disease-specific survival was poorer for patients with lymphatic invasion43% vs 62% for those who did not have lymph node involvement.
Completeness of TUR, clinical stage, and tumor grade were all significant prognostic factors. "It is obvious that smaller tumors do better than bigger tumors and also that patients with complete resection do better than patients with noncomplete resection," Dr. Brunner said.
A major concern is the 20% of patients who did not respond to radiochemotherapy. The researchers hope to develop diagnostic tests to identify these patients and the most effective treatment for each patient group, he concluded, calling the current results "good, but not good enough."