(UroToday.com) In anticipation of the 2021 American Urological Association (AUA) Annual Meeting which is being held, in a delayed fashion, in September, the AUA hosted a “May Kick-Off Weekend” which highlighted a variety of important topics in both benign urology and urologic oncology. Saturday afternoon, Adam Feldman led a course entitled “Trimodality Therapy (TMT) for Management of Muscle Invasive Bladder Cancer” along with faculty Richard Lee and Jason Efstathiou.
Following talks discussing the rationale for TMT, radiotherapy and chemotherapy considerations for its use, and surveillance following TMT and management of TMT failures, Dr. Efstathiou presented on the important issue of quality of life following TMT. Notable, the principle of TMT is to preserve the bladder, thus, it is critically important that the bladder is functional in a way that makes it worth preserving.
In general, he suggested that toxicity is acceptable and quality of life is good following bladder preservation. Across RTOG trials, rates of grade 3 toxicity are generally low: 5.7% for genitourinary toxicity, 1.9% for gastrointestinal toxicity, and 7.6% overall. Rates were even lower in the BC2001 trial. Additionally, though he did not present data to support it, he felt that outcomes have improved over time with improvements and changes in radiotherapy delivery.
However, relying on older data, he highlighted urodynamic and quality of life studies performed in the MGH cohort for patients treated prior to 2000. These demonstrated that 78% of patients had compliant bladders with normal capacity and flow parameters. Further, 25% of patients had occasional to moderate bowel control symptoms and 50% of men had reported normal erectile function. Utilizing a metric similar to the AUA symptom index quality of life question, nearly 90% of patients following TMT reported being most satisfied or better with their quality of life due to urinary symptoms.
As the randomized trial comparing radical cystectomy to TMT (SPARE) failed to accrue, there are no randomized data to assess this question. However, it is clear that both approaches have effects on the overall quality of life, urinary, bowel, and sexual function, and self-image. A cross-sectional study from the Karolinska Institute in Sweden suggested that urinary function was minimally impaired in nearly three-quarters of patients undergoing radiotherapy. Moderate or greater bowel distress was more common in patients following radiotherapy (32%) than after surgery (24%) or controls (9%). Sexual function was better following radiotherapy with a greater proportion of patients reporting having had intercourse in the last month. These findings corroborate a recent systematic review of two prospective and four retrospective observational studies of quality of life after TMT.
Dr. Efstathiou then discussed data from a pooled experience from MGH and UNC in which six validated quality of life metrics were administered to patients with MIBC who had received TMT (37%) or cystectomy (63%) and were disease-free for at least two years.
The authors found that both treatment approaches were associated with good long-term quality of life outcomes. However, TMT was associated with similar urinary scores, modestly worse bowel function, but markedly better sexual function. Highlighting differences at baseline, patients who underwent TMT had better informed decision-making.
Despite the use of validated measures, this study, like the others, is limited by the retrospective nature. Acknowledging the critical importance of the data used to populate Markov models, he briefly discussed a decision analysis of TMT and radical cystectomy which suggested potential improvements in quality-adjusted life years for patients treated with TMT.
Presented by: Jason Efstathiou, MD, DPhil, Radiation Oncologist, Professor of Radiation Oncology, Harvard Medical School, Director, Genitourinary Service, Department of Radiation Oncology, Clinical Co-Director, The Claire and John Bertucci Center for Genitourinary Cancers
Written by: Christopher J.D. Wallis, Urologic Oncology Fellow, Vanderbilt University Medical Center, @WallisCJD on Twitter during the AUA2021 May Kick-off Weekend May 21-23