Download - Treatment Options for Cancer of the Bladder
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The Treatment of Cancer of the
Bladderwww.aboutcancer.com
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Bladder Cancer
Understanding bladder cancer
Treatment options of bladder cancer (surgery, radiation, chemotherapy)
Radiation techniques and side effects
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NCCN.org
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www.nccn.org
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Treatment of Bladder CancerEarly 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
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cystoscope
bladderurethra
prostate
Cystoscopy
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TURB
Trans Urethral Resection
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Chemotherapy into the Bladder
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Treatment of Bladder CancerEarly 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
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Surgery
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Surgery
Total Cystectomy Partial Cystectomy
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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.
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Surgery Results
Stage Relapse Survival
pT2 20-30% 66%pT3 40-60% 35%pT4 70-90% 27%
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Treatment of Bladder CancerEarly 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
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Radiation Therapy
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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
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PostOperative Radiation
International Journal of Radiation Oncology • Biology • Physics, Vol. 45, Issue 3, p221–222, 1999
Status at 5 Years
Cystectomy Cystectomy + 50Gy
Pelvic Control78% 88%
Cancer Specific Survival40% 62%
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PostOperative Radiation
International Journal of Radiation Oncology • Biology • Physics, Vol. 45, Issue 3, p221–222, 1999
Status at 5 Years
Cystectomy Cystectomy + 50Gy
Pelvic Control78% 88%
Cancer Specific Survival40% 62%
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NCCN Guidelines 2014? Role for PostOp Radiation
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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
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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
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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
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Bladder Preservation Protocol
• Maximal TURB• Chemoradiation to 40-45Gy• Repeat Cystoscopy
• If no disease complete chemoradiation go 60-66Gy
• If residual tumor then cystectomy
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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%
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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.
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Chemoradiation trials of Bladder Cancer from the RTOG
• Complete Response: 59 – 81%• 80% of Long Term Survivors had
intact bladder
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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 Survival71% 65%
IJROBP 2012;84:S121
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Radiation used as primary treatment for muscle invading bladder cancer
US 10%Scandinavia 25%UK > 50%
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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
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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%
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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
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Radiation plus Chemotherapy is Superior to Radiation Alone
+
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Concurrent cisplatin and preoperative or definitive radiation. NCIC Clinical Trials group.
Coppin CM J Clin Oncol1996;14(11):2901–2907.
Treatment Pelvic RelapseChemo + Radiation 15/51 (29%)Radiation Alone 25/48 (52%)
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5 Year Survival with Radiation for muscle invading bladder cancer
Radiation alone 34 – 39% Chemo-Radiation 51%
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Bladder Preservation Trials
Therapy Complete Response 5 YearSurvival
Radiation 57% 47%Rad. + cisplatin 85% 69%Rad. + carboplatin 70% 57%
Cancer Control 2013;20:189
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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
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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