Bladder Cancer

Ja Hyeon Ku

• Publisher: Academic Press
• Year: 2017
• ISBN:
  9780128099407
• Topic: Medicine
• Subtopic: Clinical Medicine

Bladder Cancer is designed for researchers and clinicians involved in urologic practice, including urologists, medical oncologists, pathologists and radiologists. It provides comprehensive guidance for treating and understanding bladder cancer and serves as an up-to-date reference reflecting evidence-based research.

The biological behavior of this disease entity shows a heterogeneous pattern with diverse morbidity and mortality depending on a variety of factors, such as tumor characteristics (tumor stage, grade, size, number, shape, and histologic subtypes) and applied treatment modalities (surgery or non-surgical management).

This book presents the substantial academic developments in the field of bladder cancer in one convenient reference.

• Presents a comprehensive overview of the basic and translational research into bladder cancer
• Provides the established guidelines for bladder cancer in real clinical practice and relevant evidence-based research
• Saves academic, medical and cancer researchers time in quickly accessing the very latest details on bladder cancer, as opposed to searching through multiple sources
• Assists academic clinicians in understanding the importance of the breakthroughs that are contributing to advances in bladder cancer research

Section V

Treatment for Muscle-Invasive Bladder Cancer (MIBC)

Outline

Chapter 22 Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer

Chapter 23 Radical Cystectomy (RC) with Urinary Diversion

Chapter 24 Open Techniques and Extent (Including Pelvic Lymphadenectomy)

Chapter 25 Morbidity, Mortality, and Survival for Radical Cystectomy

Chapter 26 Adjuvant Chemotherapy

Chapter 27 Bladder-Sparing Treatments

Chapter 28 Quality of Life in Bladder Cancer Patients

Chapter 22

Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer

Ho Kyung Seo¹, Whi-An Kwon² and Sung Han Kim¹, ¹Research Institute and National Cancer Center, Goyang, South Korea, ²Wonkwang University Sanbon Hospital, Gunpo, South Korea

Abstract

The standard management for patients with muscle-invasive bladder cancer (MIBC) involves radical cystectomy and pelvic lymph node dissection. Although this treatment may be curative, a large proportion of patients will develop recurrence and will ultimately die because of metastatic disease. Prospective randomized clinical trials have revealed a survival advantage for patients who receive neoadjuvant chemotherapy (NAC) before radical cystectomy, and this concept has been confirmed using meta-analysis. Moreover, cisplatin-based combination NAC has consistently provided a survival benefit of 5%, and pathological downstaging is used as a surrogate endpoint for evaluating its efficacy. The efficacy of NAC for MIBC has primarily been established for regimens with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), which provide complete response rates (pT0) as high as 38%. Dose-dense MVAC is preferred over standard MVAC, and gemcitabine/cisplatin is a reasonable alternative to standard MVAC for NAC.

Keywords

Bladder cancer; cystectomy; neoadjuvant chemotherapy; efficacy; cisplatin

Chapter Outline

Introduction 337

Basis of NAC for Bladder Cancer 338

Response of Bladder Cancer to NAC 338

Surrogate Markers for the Efficacy of NAC 340

Anticancer Agents and Durations for NAC 343

NAC for Patients With Renal Insufficiency 345

Selecting Surgery Based on the Response to NAC 345

NAC and AC 346

Trends in the Clinical Application of NAC 346

Summary 346

References 348

Introduction

Bladder cancer is diagnosed in approximately 74,000 patients in the United States and approximately 450,000 new cases are diagnosed worldwide each year. Bladder cancer is the fourth most common cancer in men and the 11th most common cancer in women, with approximately 165,000 related deaths worldwide [1,2]. In Korea, the Korean National Cancer Registry reported that bladder cancer was the 12th most common type of cancer during 2013, with an estimated 3762 newly diagnosed patients [3]. Approximately 20% of all newly diagnosed bladder cancer cases involve muscle-invasive bladder cancer (MIBC), and 20% of non-muscle-invasive bladder cancers (NMIBCs) eventually progress to muscle-invasive disease [4,5]. Radical cystectomy and bilateral pelvic lymphadenectomy are the standard treatment for MIBC. However, nearly half of all patients who undergo only radical cystectomy will progress to metastatic disease within 2 years, which eventually results in death [6–8].

Neoadjuvant chemotherapy (NAC) is an effective treatment for controlling various types of solid tumors, such as breast and colon cancers [9–13]. Multiple randomized controlled studies have been performed to define the effectiveness of cisplatin-based NAC before cystectomy for bladder cancer. Unfortunately, many of these studies were limited by inadequate statistical power and the absence of a standardized surgical approach, and were unable to clearly demonstrate a survival advantage for NAC. Grossman et al. [14] performed a prospective study of patients with MIBC in 2003 and found that cisplatin-based NAC provided an improved survival rate, and a 2005 meta-analysis of 11 prospective studies confirmed the benefits of NAC [15]. The National Comprehensive Cancer Network and the European Association of Urology guidelines have subsequently recommended NAC as a standard treatment for MIBC [16,17].

Basis of NAC for Bladder Cancer

The goal of NAC is to remove micrometastases, reduce recurrence, and increase survival. In theory, micrometastases respond better to chemotherapy, compared to treatment for macrometastases that are accompanied by radiographically detected distant metastasis [18]. Compared to adjuvant chemotherapy (AC), NAC provides several advantages. First, patients tolerate NAC treatment better, as it is administered before surgery compromises their physical status, and postoperative complications can result in delayed chemotherapy administration. Second, it is easier to evaluate the tumor’s response to NAC because the NAC is administered before the tumor is resected. Third, NAC can potentially downstage bulky and locally advanced tumors, which increases the likelihood of achieving the negative surgical margins that predict local recurrence after cystectomy. Finally, micrometastases can be effectively treated at an early stage. Nevertheless, NAC is associated with several disadvantages, such as delaying definitive local therapy for patients who do not respond the chemotherapy. These patients can experience disease progression, the development of chemotherapy-associated complications (e.g., infection that can preclude surgery), and the possibility of overtreatment [19–21].

Response of Bladder Cancer to NAC

In metastatic breast and colon cancers, chemotherapy provides response rates of 35%–60% [22–25] and 17%–36% [26], respectively. Bladder cancer is also sensitive to chemotherapy, and treatment for metastatic bladder cancer using methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC chemotherapy) provides a response rate of 50%–70% and complete remission in 12%–40% of cases [27–30]. Thus, it is possible that NAC using MVAC may be useful for treating bladder cancer. Many studies have explored the role of NAC in MIBC although most studies were underpowered to detect a significant difference in the survival rate and the surgical techniques were an important confounding factor.

The European Organization for Research and Treatment of Cancer (EORTC) and the Medical Research Council (MRC) performed the largest Phase III trial of NAC for bladder cancer (BA06 30894) [31]. That study investigated the effe...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of Contributors
• About the Editor
• Preface
• Section I: Epidemiology, Etiology, and Pathophysiology
• Section II: Diagnosis
• Section III: Pathology and Staging
• Section IV: Treatment for Nonmuscle Invasive Bladder Cancer (NMIBC)
• Section V: Treatment for Muscle-Invasive Bladder Cancer (MIBC)
• Section VI: Chemotherapy for Metastatic Bladder Cancer
• Section VII: Follow-Up (Surveillance)
• Section VIII: Future Perspective in Bladder Cancer
• Index