Bladder Sparing with Radiotherapy in Patients with Clinically Node-Positive Non Metastatic Bladder Cancer

Patients with clinically node-positive (cN+) bladder cancer have a worse prognosis than patients without node involvement. Nevertheless, most treatments are more established in patients with node-negative bladder cancer. This includes favorable bladder-sparing protocols that consist of transurethral resection of bladder tumor (TURBT) followed by radical dose radiotherapy with a concurrent radiosensitizing agent. A recent study by Swinton et al. characterized clinical outcomes among patients with cN+ bladder cancer across different treatment modalities.

The analysis was carried out on a cohort of 287 patients. The median follow-up time was 4.53 years (95% CI, 4.19-5.81). Over half of the patients (57%) received radical treatment, either in the form of radical cystectomy (RC) or radical dose radiotherapy (RadRT). Most patients who received RadRT (n = 87) completed all planned fractions, and the most common dose regimen was between 50 and 55 Gy (n = 68). Regarding the treatment field, 67.8% of patients received RadRT in the bladder alone, while the rest received treatment in the bladder and lymph nodes. Moreover, 46 out of 87 patients receiving RadRT were also treated with a radiosensitizer, which was either concurrent chemotherapy (gemcitabine, mitomycin, 5-FU; n = 35) or inhaled carbogen and oral nicotinamide (n = 11).

There were 220 deaths overall, and the median overall survival (OS) was 1.55 years (95% CI, 1.35-1.82). Median progression-free survival (PFS) was 0.95 years (95% CI, 0.89-1.13), with 232 progression or death events. Radical treatment was associated with improved OS and PFS relative to palliative treatment (p < 0.0001). Among those receiving radical treatment, median OS was 2.4 years (95% CI, 1.9-2.8), and 2-year OS of 56% (95% CI, 48-64). Patients receiving palliative treatments had a median OS of 0.89 years (95% CI, 0.67-1.1) and 2-year OS of 18% (95% CI, 12-26). There were no differences in survival between the two subgroups of radical treatment. In a multivariate analysis, chemotherapy was associated with improved OS (p = 0.011) and PFS (p < 0.01), while higher cN status at diagnosis was associated with poorer OS and PFS (p = 0.007). Receiving chemotherapy was associated with improved OS (HR, 0.53; 95% CI, 0.32 to 0.87; P 5 .011) and PFS (HR, 0.43; 95% CI, 0.27 to 0.69; P < .01). A higher cN status at diagnosis (cN2/3 v cN1) was associated with a worse OS (HR, 1.72; 95% CI, 1.07 to 2.76) and PFS (HR, 1.82; 95% CI, 1.18 to 2.81; P 5 .007). There were no differences in survival between those who received RadRT to bladder alone versus bladder and lymph nodes. Similarly, radiosensitizer use was not associated with a change in survival.

This study confirms the clinical benefit of a radical approach with cN+ bladder cancer patients. Importantly, there is no difference between radiotherapy and surgery, allowing the use of bladder-sparing protocols.
Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine

Reference:

Swinton M, Mariam NBG, Tan JL, et al. Bladder-Sparing Treatment With Radical Dose Radiotherapy Is an Effective Alternative to Radical Cystectomy in Patients With Clinically Node-Positive Nonmetastatic Bladder Cancer [published online ahead of print, 2023 Jul 21]. J Clin Oncol. 2023;JCO2300725.

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