2. UroToday Home
  3. Center Of Excellence
  4. Trimodality Therapy
  5. From The Editor

Introduction to the Trimodality Therapy - Bladder Cancer Center of Excellence

Muscle-invasive bladder cancer (MIBC) represents 1/3 of the approximately 81,000 newly diagnosed bladder cancer cases in the US each year.1 Cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) has been the traditional and most widely used management approach to MIBC.

The NCCN has two category 1 treatment options for select patients with node-negative, non-metastatic MIBC: RC and tri-modality therapy (TMT). TMT consists of transurethral resection of the bladder tumor (TURBT) followed by chemoradiotherapy and offers patients the option to preserve their bladders.

While we do not have randomized data comparing RC to TMT, both RC and TMT are associated with long-term disease control rates of 50-80%.2–6 Single and multi-institutional matched comparisons of TMT to RC showed that at 5 years, metastasis-free, distant failure-free, and pelvic nodal failure-free survival were not statistically different between RC and TMT with CSS and OS favoring TMT.5,7  Additionally, modern-day salvage cystectomy rates following TMT are approximately 15%.2

Even with exceptional surgical advances in specialized centers, RC results in life-altering urinary diversion with associated changes in health-related quality of life (HRQoL) and a 90-day mortality rate of 2.5%8.  TMT has different effects on QOL than RC but when comparing patient reported HRQoL long-term outcomes, TMT has less negative effects on HRQoL than RC9 with late grade ≥3 GU and GI toxicity rates following TMT are 6% and 2%, respectively.3

UroToday’s Bladder Preservation Center of Excellence aims to provide readers with information on TMT, access to up-to-date literature on this treatment modality as well as discussions/debate about the right candidates for this treatment option.

Purpose:

Education so that we can offer patients the treatment that is best for them. 

Despite the NCCN having two category 1 treatment options for patients with node-negative, non-metastatic MIBC, a National Cancer Database (NCDB) study, showed that only 52% of patients with cT2-T4 MIBC receive curative-intent therapy with over 25% receiving observation alone.10 We need to understand different options for patients to provide recommendations that allow for shared decision making with our patients.

Objectives:

  • Highlight data and provide clinical discussions on TMT so that we can have up to date converstations with patients on its role as a curative treatment modality.
  • Update providers on clinical trials/new research in bladder preservation
  • Provide multidisciplinary discussion and perspective on TMT
  • Provide an easy access resource center for providers interested in TMT


Written by: Leslie Ballas, MD, Department of Radiation Oncology, Cedars Sinai Medical Center, Los Angeles, California

References

  1. American Cancer Society. Key Statistics for Bladder Cancer. Accessed September 7, 2022. cancer.org/cancer/bladder-cacner/about/key-statistics.html
  2. Giacalone NJ, Shipley WU, Clayman RH, et al. Long-term Outcomes After Bladder-preserving Tri-modality Therapy for Patients with Muscle-invasive Bladder Cancer: An Updated Analysis of the Massachusetts General Hospital Experience. Eur Urol. 2017;71(6):952-960. doi:10.1016/j.eururo.2016.12.020
  3. Mak RH, Hunt D, Shipley WU, et al. Long-term outcomes in patients with muscle-invasive bladder cancer after selective bladder-preserving combined-modality therapy: a pooled analysis of Radiation Therapy Oncology Group protocols 8802, 8903, 9506, 9706, 9906, and 0233. J Clin Oncol. 2014;32(34):3801-3809. doi:10.1200/JCO.2014.57.5548
  4. Vashistha V, Wang H, Mazzone A, et al. Radical Cystectomy Compared to Combined Modality Treatment for Muscle-Invasive Bladder Cancer: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys. 2017;97(5):1002-1020. doi:10.1016/j.ijrobp.2016.11.056
  5. Kulkarni GS, Hermanns T, Wei Y, et al. Propensity Score Analysis of Radical Cystectomy Versus Bladder-Sparing Trimodal Therapy in the Setting of a Multidisciplinary Bladder Cancer Clinic. J Clin Oncol. 2017;35(20):2299-2305. doi:10.1200/JCO.2016.69.2327
  6. Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med. 2003;349(9):859-866. doi:10.1056/NEJMoa022148
  7. Zlotta AR, Ballas LK, Niemierko A, et al. Multi-institutional matched comparison of radical cystectomy to trimodality therapy for muscle-invasive bladder cancer. JCO. 2022;40(6_suppl):433-433. doi:10.1200/JCO.2022.40.6_suppl.433
  8. Novotny V, Hakenberg OW, Wiessner D, et al. Perioperative complications of radical cystectomy in a contemporary series. Eur Urol. 2007;51(2):397-401; discussion 401-402. doi:10.1016/j.eururo.2006.06.014
  9. Mak KS, Smith AB, Eidelman A, et al. Quality of Life in Long-term Survivors of Muscle-Invasive Bladder Cancer. Int J Radiat Oncol Biol Phys. 2016 Dec 1;96(5):1028-1036. DOI: 10.1016/j.ijrobp.2016.08.023.
  10. Gray PJ, Fedewa SA, Shipley WU, et al. Use of potentially curative therapies for muscle-invasive bladder cancer in the United States: results from the National Cancer Data Base. Eur Urol. 2013;63(5):823-829. doi:10.1016/j.eururo.2012.11.015