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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

By: Nicholas J. Giacalonea b, William U. Shipleya, Rebecca H. Claymana, Andrzej Niemierkoa, Michael Drumma, Niall M. Heneyc, Marc D. Michaelsond, Richard J. Leed, Philip J. Saylord, Matthew F. Wszolekc, Adam S. Feldmanc, Douglas M. Dahlc, Anthony L. Zietmana and Jason A. Efstathioua

European Urology, January 2017

Published online: 10 January 2017

Keywords: Bladder cancer, Radiation therapy, Chemotherapy, Tri-modality therapy

Abstract Full Text Full Text PDF (1,0 MB)

Abstract

Background

Tri-modality therapy (TMT) is a recognized treatment strategy for selected patients with muscle-invasive bladder cancer (MIBC).

Objective

Report long-term outcomes of patients with MIBC treated by TMT.

Design, setting, and participants

Four hundred and seventy-five patients with cT2–T4a MIBC were enrolled on protocols or treated as per protocol at the Massachusetts General Hospital between 1986 and 2013.

Intervention

Patients underwent transurethral resection of bladder tumor followed by concurrent radiation and chemotherapy. Patients with less than a complete response (CR) to chemoradiation or with an invasive recurrence were recommended to undergo salvage radical cystectomy.

Outcome measurements and statistical analysis

Disease-specific survival (DSS) and overall survival (OS) were calculated using the Kaplan-Meier method.

Results and limitations

Median follow-up for surviving patients was 7.21 yr. Five- and 10-yr DSS rates were 66% and 59%, respectively. Five- and 10-yr OS rates were 57% and 39%, respectively. The risk of salvage cystectomy at 5 yr was 29%. In multivariate analyses, T2 disease (OS hazard ratio [HR]: 0.57, 95% confidence interval [CI]: 0.44–0.75, DSS HR: 0.51, 95% CI: 0.36–0.73), CR to chemoradiation (OS HR: 0.61, 95% CI: 0.46–0.81, DSS HR: 0.49, 95% CI: 0.34–0.71), and presence of tumor-associated carcinoma in situ (OS HR: 1.56, 95% CI: 1.17–2.08, DSS HR: 1.50, 95% CI: 1.03–2.17) were significant predictors for OS and DSS. When evaluating our cohort over treatment eras, rates of CR improved from 66% to 88% and 5-yr DSS improved from 60% to 84% during the eras of 1986–1995 to 2005–2013, while the 5-yr risk of salvage radical cystectomy rate decreased from 42% to 16%.

Conclusions

These data demonstrate high rates of CR and bladder preservation in patients receiving TMT, and confirm DSS rates similar to modern cystectomy series. Contemporary results are particularly encouraging, and therefore TMT should be discussed and offered as a treatment option for selected patients.

Patient summary

Tri-modality therapy is an alternative to radical cystectomy for patients with muscle-invasive bladder cancer, and is associated with comparable long-term survival and high rates of bladder preservation.

Take Home Message

Our data demonstrate high rates of complete response and bladder preservation in patients receiving tri-modality therapy, and confirm disease-specific survival rates similar to modern cystectomy series. Tri-modality therapy should be considered an appropriate and efficacious alternative to radical cystectomy in selected patients.

Keywords: Bladder cancer, Radiation therapy, Chemotherapy, Tri-modality therapy.

Footnotes

a Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA

b Harvard Radiation Oncology Program, Boston, MA, USA

c Department of Urology, Massachusetts General Hospital, Boston, MA, USA

d Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

Corresponding author. Department of Radiation Oncology, Massachusetts General Hospital, 100 Blossom Street, Cox 3, Boston, MA 02114-2606, USA. Tel. +1 617 726 5866; Fax: +1 617 726 3603.

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