A 10-Year Retrospective Review of a Nonrandomized Cohort of 458 Patients Undergoing Radical Radiotherapy or Cystectomy in Yorkshire, UK

doi:10.1016/j.ijrobp.2009.04.050

International Journal of Radiation OncologyBiologyPhysics

Volume 77, Issue 1, 1 May 2010, Pages 119-124

https://doi.org/10.1016/j.ijrobp.2009.04.050 Get rights and content

Purpose

We have previously reported on the mortality, morbidity, and 5-year survival of 458 patients who underwent radical radiotherapy or surgery for invasive bladder cancer in Yorkshire from 1993 to 1996. We aim to present the 10-year outcomes of these patients and to reassess factors predicting survival.

Methods and Materials

The Northern and Yorkshire Cancer Registry identified 458 patients whose cases were subjected to Kaplan-Meier all-cause survival analyses, and a retrospective casenote analysis was undertaken on 398 (87%) for univariate and multivariate Cox proportional hazards modeling. Additional proportional hazards regression modeling was used to assess the statistical significance of variables on overall survival.

Results

The ratio of radiotherapy to cystectomy was 3:1. There was no significant difference in overall 10-year survival between those who underwent radiotherapy (22%) and radical cystectomy (24%). Univariate analyses suggested that female sex, performance status, hydronephrosis and clinical T stage, were associated with an inferior outcome at 10 years. Patient age, tumor grade, treatment delay, and caseload factors were not significant. Multivariate analysis models were created for 0–2 and 2–10 years after treatment. There were no significant differences in treatment for 0–2 years; however, after 2 years follow-up there was some evidence of increased survival for patients receiving surgery compared with radiotherapy (hazard ratio 0.66, 95% confidence interval: 0.44–1.01, p = 0.06).

Conclusions

a 10-year minimum follow-up has rarely been reported after radical treatment for invasive bladder cancer. At 10 years, there was no statistical difference in all-cause survival between surgery and radiotherapy treatment modalities.

Introduction

Bladder cancer remains a significant health problem in the United Kingdom, accounting for 4,734 deaths in 2005 (1). The optimal treatment for muscle-invasive transitional carcinoma is still open to debate. Historically, radical treatment options for transitional cell carcinoma (TCC) constituted surgery, which was favored in the United States, whereas many centers in Europe (particularly the U.K.) reserved surgery for cases in which radical external beam radiotherapy (RT) had been unsuccessful. Current European Urological Association guidelines suggest that RT alone should be considered as a therapeutic option only in patients unfit for radical cystectomy, with multimodality transurethral resection of the bladder tumor, RT, and chemotherapy regimens an option (2). However, randomized or controlled studies examining the efficacy of treatments for invasive bladder cancer are scarce, so such recommendations are not based on high-quality evidence.

In 2003, we reported on the mortality, morbidity, and 5-year survival of 458 patients who underwent radical RT and/or surgery for invasive bladder cancer in Yorkshire between 1993 and 1996 (3), and we have continued surveillance of this cohort for a further 5 years.

The aim of this study was to present the survival of these patients 10 years after their primary treatment. The primary outcome measure was all-cause mortality, recorded by the Northern and Yorkshire Cancer Registry and Information Service (NYCRIS). In addition, we repeated proportional hazards regression modeling to identify patient, disease, and treatment parameters that correlate with the likelihood of 10-year survival.

Section snippets

Methods and Materials

The patient cohort has been described in detail previously (3). NYCRIS is a population-based cancer registry collecting data on all cancers in the Northern and Yorkshire areas of England. From the NCYRIS database, all bladder cancer patients who were treated with RT or radical cystectomy between 1993 and 1996 were identified. NYCRIS identified 348 patients who had undergone radical RT. Survival data were available for 347 patients, and casenotes were reviewed in 302. Similarly, 110 patients

Results

The patient details are shown in Table 1. The mean age for those undergoing surgery was 5 years younger than for those undergoing RT. The American Society of Anesthesiologists (ASA) grades taken from the initial endoscopic resection were similar in both treatment groups, but a preponderance of neurologic, cardiac, and respiratory problems were seen in those receiving RT.

The tumors were clinically staged according to the 1987 TNM classification. Cross-sectional computed tomography/magnetic

Discussion

Evidence from controlled clinical trials is sparse to inform treatment choices for invasive bladder cancer. In this environment we chose to investigate the outcome of radical TCC treatments in a large but defined area of the U.K. Our first paper, published in 2003 in European Urology, looked at 5-year survival, factors predicting survival, and perioperative mortality and morbidity for a cohort of 458 patients undergoing primary treatment between 1993 and 1996 (3). We were unable to demonstrate

References (20)

R. Chahal et al.
A study of the morbidity, mortality and long-term survival following radical cystectomy and radical radiotherapy in the treatment of invasive bladder cancer in Yorkshire
Eur Urol
(2003)
P.W. Chung et al.
Long-term outcome of radiation-based conservation therapy for invasive bladder cancer
Urol Oncol
(2007)
W. Duncan et al.
The results of a series of 963 patients with transitional cell carcinoma of the urinary bladder primarily treated by radical megavoltage X-ray therapy
Radiother Oncol
(1986)
R.A. Scrimger et al.
Muscle-invasive transitional cell carcinoma of the urinary bladder: A population-based study of patterns of care and prognostic factors
Int J Radiat Oncol Biol Phys
(2001)
S. Kotwal et al.
Similar treatment outcomes for radical cystectomy and radical radiotherapy in invasive bladder cancer treated at a United Kingdom specialist treatment center
Int J Radiat Oncol Biol Phys
(2008)
UK Bladder Cancer mortality statistics. 2005. Accessed 2008 at...
A. Stenzl et al.
Guidelines on bladder cancer: muscle invasive and metastatic
Arnhem: Drukkerij
(2008)
Period and cohort life expectancy tables. 2008. Accessed 2008 at...
J.P. Stein et al.
Radical cystectomy in the treatment of invasive bladder cancer: Long-term results in 1,054 patients
J Clin Oncol
(2001)
C.R. Bell et al.
Contemporary results of radical radiotherapy for bladder transitional cell carcinoma in a district general hospital with cancer-centre status
BJU Int
(1999)

There are more references available in the full text version of this article.

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Radical cystectomy is long considered as the "gold standard" in the management of localized muscle-invasive bladder cancer (MIBC), and curative intent radiotherapy is relegated to those with either inoperable tumors or with multiple co-morbidities precluding surgery. This is despite a large volume of data showing equal survival between the two modalities of treatment in this setting. In this work we seek to dispel some common myths surrounding curative intent radiotherapy as part of a bladder preservation strategy in MIBC. Baseless claims of inferior outcomes and perceived contraindications for bladder preservation are debunked along with unfounded doubts relating to hypofractionation. Finally, we caution against using response to neoadjuvant chemotherapy as a predictive biomarker for treatment selection and conclude by recommending that trimodality bladder preservation be offered as a therapeutic option that is in clinical equipoise with radical cystectomy.
Optimisation of Radiation Therapy in Bladder Preservation Therapy for Patients With Clinical Stage T2N0M0 Bladder Cancer
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A novel bladder preservation therapy, the OMC (Osaka Medical College) regimen, which combines radiation therapy with balloon-occluded arterial infusion of anticancer agents, is a treatment option for patients with muscle-invasive bladder cancer (MIBC). We retrospectively analysed the effects of changes in radiation dose and irradiation field on treatment efficacy and adverse events.The purpose of this study is to use the results of this study to help determine a course of radiation therapy for bladder preservation therapy of cT2N0M0 MIBC.
We examined 352 patients with clinical stage T2N0M0 (cT2N0M0) MIBC classified into the following groups based on the irradiation method: group A, the whole pelvis (50 Gy/25 fractions) + local bladder (10 Gy/5 fractions); group B, the small pelvis (50 Gy/25 fractions) + local bladder (10 Gy/5 fractions); group C, the whole pelvis (40 Gy/20 fractions) + local bladder (10 Gy/5 fractions).
The complete response rate, 3-year overall survival and progression-free survival rates in group A were 92.9%, 94.9% and 82.1%, respectively; in group B were 87.2%, 86.7% and 76.7%, respectively; and in group C were 95.2%, 92.6% and 71.1%, respectively. No significant differences between the groups were noted. The incidence of ≥grade 3 urinary tract and gastrointestinal toxicities were not significantly different among the groups (group A: 7.8%, 1.7%; B, 11.1%, 0%; C, 7.1%, 1.8%, respectively). The 3-year progression-free rates of the common iliac lymph node (CILN) region in patients who received whole-pelvis and small-pelvis irradiation were 99.0 and 89.0% (P < 0.01), respectively, with the latter group having significantly high lymph node recurrence in the CILN region.
Our findings showed that the optimal radiation therapy for patients with cT2N0M0 MIBC undergoing the OMC regimen is whole-pelvis irradiation including the CILN region, with a total dose of 50 Gy/25 fractions.
Overcoming the Chasm Between Evidence and Routine Practice for Bladder Cancer; Just a Quixotic Notion?
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There has been a failure to improve outcomes in bladder cancer over the last 30 years. This is despite clinical trial evidence showing a benefit of interventions such as neoadjuvant chemotherapy or concurrent radiosensitisation for non-metastatic muscle-invasive bladder cancer. The bladder cancer population is characteristically elderly, who typically suffer from multiple comorbidities. Historically, radical cystectomy has been heralded as the treatment of choice, with radiotherapy being reserved for those with inoperable tumours or those unfit for major pelvic surgery, despite a lack of robust comparative or quality of life data to support one treatment recommendation over the other. Although patients with non-metastatic muscle-invasive bladder cancer have potentially curable disease, a growing body of population-based analyses persistently highlights that most patients do not undergo curative-intent treatments – a trend that remains static. The causes for the disparity between evidence and routine practice is not clearly understood. Here, the facets of patient-centred evidence-based care, with respect to bladder conservation therapy, are examined, with proposals to reverse this unacceptable status quo.
Treatment of muscle-invasive bladder cancer in patients without comorbidities and fit for surgery: Trimodality therapy vs radical cystectomy. Development of GRADE (Grades of Recommendation, Assessment, Development and Evaluation) recommendation by the Italian Association of Radiotherapy and Clinical Oncology (AIRO)
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Citation Excerpt :
Results showed higher mortality rate for patients in the RC group (15 vs 3.3 %, respectively). Of note, direct applicability of these results to patients undergoing TMT is uncertain, considering that patients in this series were not treated with concomitant CT (Munro et al., 2010). The literature search returned 210 records after duplicates removal.
To compare trimodality therapy (TMT) versus radical cystectomy (RC) and develop GRADE (Grades of Recommendation, Assessment, Development and Evaluation) Recommendation by the Italian Association of Radiotherapy and Clinical Oncology (AIRO) for treatment of muscle-invasive bladder cancer (MIBC).
Prospective and retrospective studies comparing TMT and RC for MIBC patients were included. Qualitative and quantitative evaluation of evidence was made.
Ten studies were included in the analysis. Pooled analysis showed salvage cystectomy and pathological complete response rates after TMT of 12 % and 72–77.5 %, respectively. Pooled rates of G3-G4 GU toxicity and serious toxicity rate were 18 vs 3% and 45 vs 29 % for patients undergoing TMT vs RC, respectively. The panel assessed a substantial equivalence in terms of OS and CSS at 5 years between TMT and RC.
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UK Bladder cancer survival remains low. Nonmetastatic muscle-invasive bladder cancer (MIBC) is potentially curable. It is unclear how many patients receive nonradical treatment owing to advanced age, comorbidities, or alternative factors.
To describe treatments and assess survival by disease stage and sex for all newly diagnosed nonmetastatic MIBC in England in 2016, and to observe associations between comorbidities and treatments.
All new nonmetastatic MIBC diagnoses in England in 2016 were identified retrospectively using National Cancer Registration and Analysis Service, Radiotherapy Datasets, Systemic Anti-Cancer Therapy, and Hospital Episode Statistics databases.
Age, Charlson Comorbidity Index (CCI), and treatments were ascertained, and 1-yr survival was estimated using Pohar-Perme and Kaplan-Meier methods.
Nonmetastatic MIBC diagnoses were registered for 2519 patients (median age 76 yr). Radical cystectomy was performed in 24%, 37% of whom received neoadjuvant chemotherapy (NAC). Radical radiotherapy was performed in 29%, 48% of whom received NAC. NAC alongside radical treatment was associated with higher 1-yr overall survival (OS)—91% (88–93%) with NAC and 83% (80–85%) without (p = 0.05). Nonradical treatments occurred for 47%, with corresponding lower OS. Females with stage II and III disease had significantly lower net survival (NS). Radically treated patients had lower CCIs.
This analysis provides an overview of all nonmetastatic MIBC diagnosed in England in 2016. Just over half of the patients received curative-intent treatment. Of them, only 43% received NAC. One-year OS was disparate, correlating with treatment intensity. Those receiving NAC and radical therapy demonstrated highest OS. Female patients had significantly inferior NS. The data highlight a prescient unmet research need to understand the patient demographic and reasons behind treatment allocation, to address the poor survival observed in those treated nonradically, and the low NAC utilisation. The significantly aged population requires specific future focus.
We looked at all patients in England in 2016 who were diagnosed with bladder cancer invading the bladder muscle. Many patients were elderly, and the most intensive treatments aiming for cure were frequently not used. Survival in women was found to be considerably worse, as was survival for less intensively treated patients.
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Clinical InvestigationA 10-Year Retrospective Review of a Nonrandomized Cohort of 458 Patients Undergoing Radical Radiotherapy or Cystectomy in Yorkshire, UK

Purpose

Methods and Materials

Results

Conclusions

Introduction

Section snippets

Methods and Materials

Results

Discussion

Eur Urol

Urol Oncol

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Guidelines on bladder cancer: muscle invasive and metastatic

Arnhem: Drukkerij

Radical cystectomy in the treatment of invasive bladder cancer: Long-term results in 1,054 patients

J Clin Oncol

Contemporary results of radical radiotherapy for bladder transitional cell carcinoma in a district general hospital with cancer-centre status

BJU Int

Clinical Investigation
A 10-Year Retrospective Review of a Nonrandomized Cohort of 458 Patients Undergoing Radical Radiotherapy or Cystectomy in Yorkshire, UK