Outcome following radical cystectomy and bladder-preservation therapy in patients with invasive carcinoma of urinary bladder

BACKGROUND: Invasive bladder cancer is a lethal disease with a 50% cancer-related mortality even in the best healthcare systems. Optimum combination of surgery, external beam radiotherapy and platinum-based chemotherapy has yet to be determined. PURPOSE: To audit the outcome of multi-modality treatment and compare this with the existing literature in order to set future priorities and re-audit in patients with invasive carcinoma of urinary bladder. MATERIALS AND METHODS: Between January 2001 and December 2004, 97 patients with invasive carcinoma of urinary bladder were analyzed. Radical surgery was done in 18(18%) patients and adjuvant radiation was given to 20(21%) patients. Radical radiation alone, (≥50 Gy) was given to 26(27%) and chemoradiation to 33(34%) patients respectively. Patients in the chemoradiation arm were given the same dose of radiation with weekly concomitant cisplatin at 40 mg/ m(2) one hour before radiation during the first phase only. At a median follow-up of 32 months the outcome studied included locoregional failure, distant failure, disease-free survival (DFS) and overall survival (OS) using univariate and multivariate analyses. The OS and DFS were calculated according to Kaplan-Meier. Log rank test was used for statistical significance. RESULTS: Median age of the patients was 58 years. Males comprised 93% of the total patients. Most (93%) of the patients had transitional cell histology. In patients treated with radiation alone overall response rate was 60%, with a complete response (CR) rate of 42%. The CR in patients treated with chemoradiation was 51%. Bladder was preserved in 61% of patients who received chemoradiation as compared to 42% in patients treated with radical radiation. With radical radiation local recurrence rate was 19% as compared to 22% with surgery and 6% with chemoradiation, respectively. Local recurrence rate was only 5% in patients treated with adjuvant radiation. Distant metastasis rate was least with chemoradiation (9%) as compared to 11.5% in radical radiation: curable dose of radiation and 33% with surgery alone, respectively. Patients with adjuvant radiation had a distant metastases rate of 15%. Median OS was 36 months. Factors affecting OS were histology (P = 0.023) and nodal involvement (P = 0.034). Median DFS was 26 months. Significant factors affecting DFS on univariate analysis were histology (P = 0.046) and nodal involvement (P = 0.004). On multivariate analysis the only factor affecting DFS and OS was nodal involvement (P = 0.01; Hazard Ratio, 0.085-0.719). CONCLUSION: In patients with invasive bladder cancer, combined modality in the form of radical cystectomy followed by radiation give best local control. Radiation alone is not effective to control muscle-invasive local disease; however, Chemoradiation is an effective alternative to radical cystectomy to preserve bladder function.