Bladder CancerSurvival after Bladder-Preservation with Brachytherapy versus Radical Cystectomy; A Single Institution Experience
Introduction
Conservative treatment is now standard care for numerous malignancies including breast cancer, laryngeal cancer, anal cancer and soft-tissue sarcomas. For patients with invasive bladder cancer radical surgery is still considered standard treatment. Nonetheless, there are bladder-preserving alternatives for these patients, such as treatment with brachytherapy after transurethral resection (TUR) and external beam radiotherapy (EBRT). This treatment strategy has proven to be effective for patients with solitary, organ confined, invasive bladder cancer (tumour category T1–T2) with a diameter of less than 5 cm. Reports mention high local control rates of 70–90% and excellent maintenance of bladder function [1], [2], [3], [4], [5], [6], [7], [8], [9], [10]. Despite these results there remains a reluctance to accept brachytherapy as a reasonable alternative to radical cystectomy. An important reason for this could be the commonly held belief that bladder-sparing strategies lead to inferior survival. To become a reasonable alternative to cystectomy, a bladder-sparing approach should not compromise survival. Additionally, the bladder-sparing alternative should have excellent bladder sparing capacities.
For many years it has been the policy at our institute to offer patients with solitary, T1–T2 invasive bladder cancer smaller than 5 cm the option of bladder preservation with brachytherapy. We recently published our updated results [10]. Based on local control rates brachytherapy appears to be a reasonable alternative to cystectomy. The purpose of this study was to establish whether this could be sustained in the light of evidence from our own patients regarding survival as well. The following analysis reports on the survival rates after brachytherapy and cystectomy in our institution. Furthermore we describe the chance of bladder preservation after brachytherapy, based on our previously published results [10].
Section snippets
Tumour staging
This is a retrospective review over patients treated between 1988–2003. In that time period the UICC TNM-staging changed. One of the inclusion criteria for brachytherapy is organ confined disease. Up to 1997 that included stage T3a (tumour invades in deep muscle). From 1997 onwards, T3a became T2b. We converted all stages to the 2002 TNM-system of the International Union Against Cancer [11], so a T3a tumour before 1997 is included in the analysis as T2 tumour. As no resected specimens are
Patient and tumour characteristics
Patient and tumour characteristics are shown in Table 1. Significant differences were observed in tumour stage distribution (T1 vs. T2), tumour multiplicity (solitary vs. multiple) and tumour diameter. The brachytherapy group appeared to have a higher proportion of T2 tumours than the cystectomy group. All tumours in the brachytherapy group were solitary vs. 22% of the cystectomy tumours. The majority of the brachytherapy tumours were <3 cm, while for the majority of the cystectomy group (69%)
Discussion
Radical cystectomy is standard treatment for patients with muscle invasive bladder cancer. Certainly since orthotopic bladder substitution has become available, many urologists prefer early definitive therapy with continent urinary diversion above bladder preserving strategies. Is there a role for these bladder-preserving strategies? A recent study from Sweden concluded that the patient's well-being after cystectomy with urinary diversion is considerably influenced due to changed bowel and
Conclusions
This study does not provide evidence regarding survival against the use of brachytherapy for patients with solitary, T1–T2 invasive bladder cancer of ≤5 cm diameter, seeking bladder-sparing alternatives to radical cystectomy. Of all long-term surviving patients treated with brachytherapy, 90% preserved their well functioning native bladders. We continue our policy to offer suitable patients the alternative of bladder preservation.
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Note: Both authors contributed equally to this work.