An update of combined modality therapy for patients with muscle invading bladder cancer using selective bladder preservation or cystectomy

Purpose: We update the results of tri-modality treatment for patients with muscle invading bladder tumors with selection for bladder preservation base d on tumor response to induction therapy. Material and Methods: We reviewed the literature on modern tri-modality bla dder preserving approaches using transurethral resection, radiation and con current chemotherapy followed by either bladder conservation with careful s urveillance for complete responding patients or prompt cystectomy in those whose tumors persist after induction therapy. Results: The published experiences from 3 centers and 2 prospective trials done by the Radiation Therapy Oncology Group were evaluated for 5-year over all survival of patients selected for bladder preservation or prompt cystec tomy (49 to 63%) and for those with a conserved bladder (38 to 43%). The ov erall 5-year survival rates were comparable to other series of immediate cy stectomy based approaches in patients of similar age and presenting with tu mors of similar clinical stage. Of patients treated with the bladder preser ving approach 20 to 30% cured of muscle invading cancer will subsequently h ave a new superficial tumor. The superficial tumors have responded well to intravesical drug therapy. Modern bladder preserving treatments usually res ult in a well functioning bladder without incontinence or significant hemat uria. However, concurrent systemic chemotherapy and radiation have the pote ntial for acute morbidity. Presently the ideal candidate for bladder preser vation has primary clinical stage T2 tumor, no associated ureteral obstruct ion, visibly complete transurethral resection and complete response after i nduction chemoradiation based on endoscopic evaluation including re-biopsy and cytology. Conclusions: It is recommended that tri-modality treatment be administered by dedicated multimodality teams. In this country this approach to treatmen t is available at many of the institutions participating in the Radiation T herapy Oncology Group study. This treatment may be considered a reasonable alternative in patients who are deemed medically unfit for cystectomy and f or those who are seeking an alternative to radical cystectomy.