Collaborative Review – Bladder CancerCritical Analysis of Bladder Sparing with Trimodal Therapy in Muscle-invasive Bladder Cancer: A Systematic Review
Introduction
Radical cystectomy (RC) with pelvic lymph node dissection remains widely accepted as the gold-standard treatment for muscle-invasive bladder cancer (MIBC) supported by a substantial body of evidence [1], [2], [3] with long-term follow-up. Nevertheless, removal of the bladder may lead to significant morbidity and affect patients’ comfort and quality of life (QoL) [4], [5]. Concerns about oncologic equivalence may in part explain differences in local utilisation rates of bladder preservation in eligible patients among different countries [6], [7], [8], [9].
Several bladder-preservation options exist, including single-modality treatments such as transurethral resection (TUR) alone, partial cystectomy, radiation therapy (RT), or chemotherapy alone. Nevertheless, it is generally accepted that single-modality treatments result in inferior outcomes compared with RC. A trimodal therapy (TMT) approach, including maximal TUR followed by concurrent radiosensitising chemotherapy and RT, is the most-studied bladder-sparing strategy. The aim of this systematic review was to assess the modern bladder-preservation treatment modalities, focusing on TMT in MIBC.
Section snippets
Evidence acquisition
A systematic literature search in the PubMed and Cochrane databases was performed to identify clinical and randomised controlled trials (RCTs) published from 1980 to July 2013 [10]. Various algorithms, including the following terms, were used: bladder cancer, bladder preservation, trimodality treatment, radiotherapy, chemotherapy, chemoradiation, chemoradiotherapy, organ-sparing, bladder-sparing, and salvage cystectomy. Inclusion criteria used were published full articles, clinical trials,
Evidence analysis
Overall, five prospective TMT phase 3 trials have been published, including two phase 3 RCTs. The remaining articles included in this review were large retrospective series (with heterogeneous treatment protocols) and phase 2 trials with small cohorts. Although use of conservative management for MIBC has yielded promising results and gained wider acceptance, most studies have small cohorts or limited follow-up, providing few data on long-term oncologic safety or late toxicity.
Conclusions
A growing body of accumulated data suggests that TMT (with prompt cystectomy reserved for tumour recurrence or nonresponders) leads to acceptable outcomes and may therefore be considered a reasonable treatment option in well-selected patients. TMT can be discussed not only in patients unfit for surgery but also for those patients who have MIBC and are not willing to undergo surgery.
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