THE COMBINATION OF CISPLATIN-BASED CHEMOTHERAPY AND RADIATION IN THE TREATMENT OF MUSCLE-INVADING TRANSITIONAL-CELL CANCER OF THE BLADDER

Radical cystectomy is the standard of care for patients with muscle-in vading transitional cell carcinoma of the bladder. More limited surger y is only useful in highly selected patients and radiation therapy alo ne gives overall local-control rates under 40%. Phase II studies have shown that when radiation and trans-urethral surgery are combined with cis-platin based chemotherapy local-control rates increase such that the majority of patients preserve a tumor-free functional bladder. Up to 85% of patients selected for bladder sparing therapy on the basis o f their initial response to chemo-radiation may keep their bladders. T his figure could increase further when other powerful prognostic facto rs such as the presence of hydronephrosis, the presence of carcinoma i n situ, and DNA ploidy are also taken into account in initial patient selection. The activity of cisplatin combinations in metastatic diseas e is not in doubt with up to 50% response rates generally reported. Th e hope that this will translate into the eradication of micrometastati c disease (known to be present in up to 40% of patients at diagnosis) has yet to be borne out. Those randomized trials so far reported have not shown any survival advantage when combined-modality therapy is com pared to radiation alone. The addition of combination chemotherapy to radiation does not increase bladder morbidity but carries a considerab le systemic penalty. Thus, despite promising Phase II studies, until l ocal control and survival benefit is proven in a randomized trial it s hould continue to be regarded as experimental.