Initial management
Patients are usually seen by a urologist initially for investigation of haematuria. The most common first investigation is cystoscopy and resection of visible tumour (or biopsy), from which the extent of disease can be estimated.
Management is highly dependent on the stage of disease:
- Non-invasive or minimally invasive disease (Ta, Tis, and T1 - Stage 0-I)
- Muscle invasive disease (T2, T3, T4a - Stage II/III)
- Unresectable disease (Stage IV)
Non-Invasive or minimally invasive disease
The first treatment should always be trans-urethral resection of bladder tumour (TURBT). This involves rigid cystoscopy with local excision of all visible polyps. The resected specimens are examined to confirm absence of muscle invasive disease (T2+)
Muscle Invasive Disease (T2-T4, N0, M0)
The goals of therapy are:
- Cure
- Organ preservation without compromising survival (individual circumstances may vary)
- Palliation if cure is not possible
Due to decreasing incidence there is reduced emphasis on bladder cancer (compared with prostate cancer). Curative treatment is either surgical resection versus radiation based treatment. Comparitive studies are limited due to an difference patient groups receiving surgery versus radiotherapy. Overall radiotherapy seems to perform slightly worse than surgery alone.
Evidence for radiotherapy includes:
- Retrospective data comparing outcomes for surgery and radiotherapy that show similar outcomes.
- Shelley Surgery vs Radiotherapy Cochrane review (2012) comparing pre-operative radiotherapy followed by surgery vs radical radiotherapy with salvage surgery. Overall survival was 36% at 5 years for surgical patients and 20% for radiotherapy. The study was limited by the use of older studies that used older surgical and radiotherapy techniques.
Current guidelines:
- European Urological Association: Surgery is recommended as the definitive treatment, with bladder reconstruction as the preferred option. Bladder preserving treatment is only recommended for well informed patients. Adjuvant radiotherapy
Bladder Conservation
Patients should have maximal transurethral resection of tumour.
Chemoradiotherapy following TURBT, utilising radiation in combination with cisplatin and 5-fluorouracil was explored in a prospective non-randomised trial. The bladder and regional nodes were treated to 45 Gy and the whole bladder boosted to 54-59 Gy depending on resection status.
Chemotherapy in the adjuvant setting (James 2012) explored the use of concurrent fluorouracil and mitomycin C.
Chemoradiotherapy with cisplatin alone was explored in two phase II studies - TROG 97.01 and TROG 99.06 (follow up study due to high cisplatin toxicity). Outcomes were not as good as expected.
One of the most important components of bladder conservation is follow up. Close follow up is essential with 3 monthly cystoscopies. This allows early detection of recurrence with the potential for salvage cystectomy.
Partial Bladder Irradiation
Goldsmith et all have recently published data on the extent of disease within the bladder. 95% of bladders contained tumour outside of the expected area. This makes the case for partial bladder irradiation less compelling.
Neoadjuvant Chemotherapy
Neoadjuvant therapies are becoming less popular for many different cancers but remains a popular intervention in bladder caner. Platinum based chemotherapy reduces the risk of death by 14% and survival increased from 45% to 50% in a recent Cochrane review. Single agent cisplatin is not recommended.
Randomised trial of neoajuvant cisplatin, methotrexate and vinblastine is an example study, showing a 5% increase in survival when used before local therapy.
Adjuvant Chemotherapy
Adjuvant studies are limited by small patient numbers but another Cochrane review demonstrates a 25% risk reduction if adjuvant chemotherapy is used.
