While observation may be appropriate for select cases where prognosis is poor, rates of non-treatment are unacceptably high in muscle-invasive bladder cancer.
Aaron Falchook, MD
The most common treatment for muscle-invasive bladder cancer is radical cystectomy. This procedure involves removal of the bladder, proximal urethra, perivesicular fat, pelvic lymph nodes, and either the prostate and seminal vesicles for men, or anterior vagina, uterus, and ovaries for women. A published study examining the National Cancer Database showed that radical cystectomy is the most common treatment chosen for patients under age 75, but that approximately 30% to 50% of patients older than 75 receive no definitive treatment at all.
Patient comorbidities, especially among the elderly, are an important consideration given the nature of radical cystectomy. Post-cystectomy mortality rates at 90 days range from 2% for patients younger than 70 to 9% for those aged 80 and older. Furthermore, surgery results in a permanent change to urinary tract anatomy, with reconstructive options including incontinent urinary pouch (ileal conduit), continent cutaneous reservoir, and orthotopic ileal reservoir. The impact of urinary reconstruction choice on postoperative quality of life has been widely studied, but choice of reconstruction technique may not significantly affect quality of life.
Another treatment option for bladder cancer is bladder preservation therapy. Bladder preservation therapy consists of maximal tumor removal via a transurethral resection of bladder tumor (TURBT). The TURBT is then followed by a course of radiotherapy (with or without chemotherapy). Bladder preservation can be an effective treatment strategy for patients who do not receive surgery, although the comparative efficacy of surgery vs bladder preservation therapy is not known because large modern randomized controlled trials comparing these two approaches are lacking. Both surgery and bladder preservation are accepted approaches in the management of muscle-invasive bladder cancer, per the National Comprehensive Cancer Network Guidelines. The morbidity and quality of life considerations related to surgery vs bladder preservation are therefore important considerations in treatment selection. Although many studies examine quality of life for cystectomy patients, there are fewer studies examining quality of life among patients who receive bladder preservation.
Zietman et al reported a series of patients treated at Massachusetts General Hospital with bladder preservation therapy between 1986 and 2000. Patients were asked to complete a survey and perform urodynamic studies-49 completed the survey and 32 agreed to urodynamic studies. Urodynamic function was normal in 75% of patients, and erectile function was intact in 54% of patients. Survey results for bowel and bladder symptoms were favorable: The most significant reported moderate or greater symptoms were nocturia (25% of patients) and bowel urgency (14%). Quality-of-life results from four Radiation Therapy Oncology Group (RTOG) studies involving bladder preservation therapy were reported by Efstathiou et al. With a median follow-up of over 5 years, grade 3 genitourinary toxicity was 5.7%, grade 3 gastrointestinal toxicity was 1.9%, and there were no late grade 4 or 5 toxicities reported.
It is undoubtedly true that many patients diagnosed with bladder cancer, especially the elderly, will not be candidates for radical cystectomy. While observation may be appropriate for select cases where overall prognosis is poor, rates of non-treatment remain unacceptably high for muscle-invasive bladder cancer. Combined-modality bladder preservation therapy offers an excellent strategy to maximize the probability of disease control and preserve quality of life.