Bladder CancerLong-term Outcomes After Bladder-preserving Tri-modality Therapy for Patients with Muscle-invasive Bladder Cancer: An Updated Analysis of the Massachusetts General Hospital Experience
Introduction
Radical cystectomy (RC) has long been the standard of care for the management of muscle-invasive bladder cancer (MIBC). Modern RC series have demonstrated 5-yr overall survival (OS) rates of 56–66% [1], [2], [3], [4]. The morbidity and mortality of RC are well documented [5]. There has been an increasing trend of utilizing organ-preserving therapies in the management of multiple cancers over the past several decades. In bladder cancer, a multidisciplinary approach has led to the development of bladder-sparing approaches using maximal transurethral resection (TURBT) followed by radiotherapy with concomitant radio-sensitizing chemotherapy for MIBC. There are no completed randomized studies comparing RC and TMT, but multiple series have suggested that TMT can yield favorable results in well-selected patients [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17]. Herein we report the long-term results of an updated analysis from a single institutional experience. To our knowledge, this represents the largest experience of TMT for MIBC.
Section snippets
Material and methods
This is a retrospective analysis of 475 patients with MIBC treated at the Massachusetts General Hospital (MGH) and enrolled on prospective institutional or Radiation Therapy Oncology Group (RTOG) protocols, or patients that were treated as per protocol. Further details regarding the protocol design and treatment specifics for each protocol were detailed previously [9], [10], [11], [12], [15], [18], [19], [20], [21].
Patient characteristics
Between 1986 and 2013, 475 patients with MIBC underwent TMT. Median follow-up was 4.55 yr for all patients (interquartile range [IQR]: 1.9–9.4), and 7.21 yr for surviving patients (IQR: 3.5–12.3). Full patient and tumor characteristics are listed in Table 2.
Response to induction therapy
Seventy-five percent of patients achieved a CR to chemoradiation. Patients with a visibly complete TURBT had a CR rate of 84% versus 58% in patients with a visibly incomplete TURBT (p < 0.001). When evaluated by clinical T stage, patients with
Discussion
In this large cohort of patients treated with TMT, we demonstrate favorable long-term DSS and OS, with bladder preservation possible in over 70%. Furthermore, our analyses show marked improvements in DSS when evaluated over time, with 5-yr DSS approaching 85% in the modern treatment era. Our results compare favorably with other large experiences, including the RTOG pooled analysis and a large institutional experience from the University of Erlangen [15], [23]. To our knowledge, this represents
Conclusions
In conclusion, these data demonstrate long-term outcomes for TMT similar to RC, and continue to support and establish the role for bladder-preserving TMT as an appropriate alternative to RC for well-selected patients with MIBC who are motivated to preserve their native bladder. Engaging patients in shared decision-making through multidisciplinary clinics is key to more widespread utilization of this treatment strategy, and it would be reasonable to offer it routinely, as an alternative to RC,
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