Correspondence
Bladder Preservation after Treatment of Invasive Bladder Cancer
N Engl J Med 1994; 330:867-868March 24, 1994
- Article
To the Editor:
The conclusions drawn by Kaufman et al. (Nov. 4 issue)1 in their article on selective bladder preservation by combination treatment of invasive bladder cancer do not seem to be compatible with their results. They state “Of the 53 patients studied, 20 (38 percent) survived with bladders apparently free of tumor, and 11 others (21 percent) died with tumor-free bladders; thus, the rate of bladder preservation was 58 percent.” No information is given on how long after the completion of treatment these 11 patients died, but the results in these patients can hardly be considered successful. Furthermore, to read in the Abstract that “in 31 patients (58 percent) the bladder was free of invasive tumor and functioning well” is misleading when 11 of these patients were dead. Many may not have lived long enough to have a local recurrence.
The authors continue: “In 8 patients (15 percent of all studied) among the 20 surviving with disease-free bladders, superficial tumors recurred but were successfully eradicated by intravesical drug therapy.” However, they go on to state:
During a median follow-up of four years, 3 of 28 patients (11 percent) with complete responses to the full courses of chemotherapy, radiotherapy had local recurrence of an invasive tumor. Nine patients (17 percent of the total) had recurrence of a superficial bladder cancer (carcinoma in situ in eight of these nine patients), successfully managed in eight by further transurethral surgery and intravesical drug therapy.
Apart from the numerical discrepancy, there is no indication of the type of intravesical chemotherapy used or of the length of follow-up. The rate of long-term control of carcinoma in situ in patients treated initially with this method is a little less than 58 percent2 and is likely to be much less if the disease recurs after radiation therapy and systemic chemotherapy.
A more realistic appraisal of the results indicates that only 12 of 53 patients (23 percent) were alive with a functioning disease-free bladder after a median follow-up of 48 months, and 28 percent underwent salvage cystectomy under less than ideal circumstances. Treatment was prolonged and associated with substantial morbidity.
Urinary diversion in which continence is preserved has become the accepted treatment for patients undergoing cystectomy. Most patients can be confidently offered a cystectomy and diversion in which continence is preserved, which is a single treatment with a disease-free survival rate of 64 percent for stage pT2 and pT3a tumors and 44 percent for stage pT3a and pT3b tumors at five years, with considerably less morbidity3.
3 ReferencesBernard Lytton, M.B., F.R.C.S.
Yale University School of Medicine, New Haven, CT 065101
Kaufman DS ,Shipley WU ,Griffin PP ,Heney NM ,Althausen AF ,Efird JT . Selective bladder preservation by combination treatment of invasive bladder cancer. N Engl J Med 1993;329:1377-1382
Full Text | Web of Science | Medline2
Coplen DE ,Marcus MD ,Myers JA ,Ratliff TL ,Catalona WJ . Long-term followup of patients treated with 1 or 2, 6-week courses of intravesical bacillus Calmette-Guerin: analysis of possible predictors of response free of tumor. J Urol 1990;144:652-657
Web of Science | Medline3
Skinner DG ,Lieskovsky G . Contemporary cystectomy with pelvic mode dissection compared to preoperative radiation therapy plus cystectomy in management of invasive bladder cancer. J Urol 1984;131:1069-1072
Web of Science | Medline
To the Editor:
The study by Kaufman et al. is weakened by the lack of attention to functional considerations. After all the chemotherapy, radiation therapy, and endoscopic surgery, what usable detrusor capacity remains in these patients? The subjective, retrospective assertion of patients that their bladder function after therapy “remained satisfactory” is inherently weak; pretreatment and post-treatment symptom scores would have been better for assessing the validity of this claim, as would objective determination of bladder volume before and after voiding and other urodynamic variables.
If these patients are left with a bladder remnant that is fibrotic, has a small capacity, or is painful, the value of conservative treatment pales in comparison with the benefit of definitive surgery and bladder reconstruction, which can now be offered to most patients with invasive bladder cancer.
David J. Berman, M.D.
Merrimack Urology Associates, Lowell, MA 01852Author/Editor Response
The authors reply:
To the Editor: We agree with Dr. Berman that objective data to supplement our subjective information about bladder function after radiation treatment and chemotherapy might have been desirable. However, the patient's opinion may be more meaningful than any objective measurement1-3. Bladder function was described as normal by every one of our patients; that meant they had no frequency, no incontinence, no pain on voiding, and no urgency. We can assure Dr. Berman that no patient was left with a bladder remnant that was fibrotic, had a small capacity, or was painful.
Dr. Lytton presents urinary diversion in which continence is preserved in such a positive light that one might conclude that bladder preservation is not a worthwhile goal. Such diversion is associated with substantial morbidity,4 however, and no one could ever convince a patient that his or her quality of life with an artificial bladder is even close to that with a normal bladder.
In response to Dr. Lytton's request for survival data on the 11 patients who died, the average survival of this group, from the time of entry into the protocol, was 34 months (range, 12 to 62). Dr. Lytton suggests that treatment with radiation and chemotherapy may delay radical cystectomy. In our series only 1 of 47 patients (2.1 percent) who were candidates for cystectomy had a recurrence of cancer in the pelvic area after radiation or chemotherapy. If our small series is typical, a 2 percent risk may be involved in realizing a 55 to 60 percent likelihood of maintaining a tumor-free bladder.
Dr. Lytton appropriately requests details of the treatment of carcinoma in situ. Seven of the eight patients with carcinoma in situ have been in remission for 15, 29, 30, 37, 39, 41, and 49 months with intravesical treatment with bacille Calmette-Guerin.
Dr. Lytton's final paragraph suggests to us that he did not appreciate the main thrust of our clinical trial. If there are to be improvements in the survival of patients with bladder cancer, urologists must accept the fact that bladder cancer is a systemic disease in which almost all deaths are due to the effects of distant metastases. We must not focus our attention so intently on fashioning a better artificial bladder that we lose sight of the fact that too many of our patients die of distant metastases regardless of the local treatment used. We must devise and test chemotherapy regimens even more effective than the one we used in this pilot study.
4 ReferencesDonald S. Kaufman, M.D.
William U. Shipley, M.D.
Niall M. Heney, M.D.
Alex F. Althausen, M.D.
Massachusetts General Hospital, Boston, MA 021141
Lynch WJ ,Jenkins BJ ,Fowler CG ,Hope-Stone HF ,Blandy JP . The quality of life after radical radiotherapy for bladder cancer. Br J Urol 1992;70:519-521
Medline2
Aaronson NK ,Ahmedzai S ,Bergman B , et al. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85:365-376
CrossRef | Web of Science | Medline3
Fowler FJ Jr ,Barry MJ ,Lu-Yao G ,Roman A ,Wasson J ,Wennberg JE . Patient-reported complications and follow-up treatment after radical prostatectomy: the National Medicare experience: 1988-1990 (updated June 1993). Urology 1993;42:622-629
CrossRef | Web of Science | Medline4
Studer UE . Continent urinary reservoirs. J Urol 1994;151:341-342
Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
HYUNG L. KIM, GARY D. STEINBERG. (2000) THE CURRENT STATUS OF BLADDER PRESERVATION IN THE TREATMENT OF MUSCLE INVASIVE BLADDER CANCER. The Journal of Urology627-632
CrossRef
