For patients diagnosed with clinically node-positive bladder cancer, a less invasive treatment option than traditional radical cystectomy – the complete removal of the bladder – is proving to be a viable alternative. Radical dose radiotherapy, often combined with chemotherapy, offers the potential to spare the bladder while achieving survival outcomes comparable to surgery, according to recent research.
The Burden of Bladder Cancer and the Rise of Bladder-Sparing Approaches
Bladder cancer affects hundreds of thousands globally each year. Historically, the standard treatment for muscle-invasive bladder cancer has been radical cystectomy. This procedure necessitates either living with an external urine collection bag or undergoing a reconstructive surgery to create a neobladder using intestinal tissue. While effective, these surgeries are significantly disruptive to a patient’s quality of life.
“These surgical procedures have proven their effectiveness, It’s not for us to deny them,” says Dr. Vérane Achard, a radiotherapist. “But they are disabling and the quality of life of patients is greatly impacted.”
Radiotherapy offers a potential solution, allowing clinicians to target the tumor directly without removing the bladder. However, concerns about efficacy compared to surgery have historically limited its widespread adoption, particularly in cases of clinically node-positive disease – where cancer has spread to nearby lymph nodes.
New Evidence Supports Radiotherapy as an Effective Alternative
A recent multicenter retrospective analysis, conducted across several UK Oncology centers, examined survival outcomes in patients with clinically node-positive bladder cancer (cN+ M0 BCa) treated with either radical cystectomy or radical dose radiotherapy. The study, involving 287 patients, found that overall survival rates were similar between the two treatment groups.
The median overall survival across all patients was (95% CI, ). Importantly, patients receiving radical treatments – either surgery or radiotherapy – demonstrated significantly improved overall survival (hazard ratio [HR], 0.32. 95% CI, 0.23 to 0.44; P < .001) compared to those receiving palliative care.
The study revealed no statistically significant difference in either overall survival (HR, 0.94; 95% CI, 0.63 to 1.41; P = .76) or progression-free survival (HR, 0.74; 95% CI, 0.50 to 1.08; P = .12) between patients treated with radical cystectomy and those treated with radical dose radiotherapy.
These findings suggest that, for appropriately selected patients, bladder-sparing treatment with radical dose radiotherapy can achieve comparable survival outcomes to radical cystectomy, while potentially preserving quality of life.
What to Expect with Radical Dose Radiotherapy
Radiotherapy for bladder cancer involves delivering high-energy rays, typically X-rays, to destroy cancer cells. A typical course of treatment involves daily sessions – approximately fifteen minutes each – five days a week, for a total of 20 sessions, usually over a month.
“They will be subjected to low-dose chemotherapy which accompanies radiotherapy and serves to improve its effectiveness,” explains Dr. Achard. This combination, known as trimodal therapy (TMT), is often recommended according to international guidelines.
As with any cancer treatment, radiotherapy can cause side effects. Common side effects include increased urinary frequency, a burning sensation during urination (similar to cystitis), and difficulty urinating due to bladder inflammation. Medical support is available to manage these side effects, and they typically resolve after treatment completion.
A Shift in Treatment Philosophy and Patient Choice
While the evidence supporting radiotherapy is growing, disparities in treatment approaches exist. In countries like England and Canada, patients with bladder cancer are routinely presented with both surgical and radiotherapy options, allowing them to make informed decisions based on their individual preferences and risk tolerance.
“In England or Canada, in particular, faced with this type of cancer, a nurse tells the patient that We find two treatment options: surgery or radiotherapy. Each time, he is informed of the risks and side effects involved. He will then make an informed choice,” according to observations from clinicians.
However, in France, the decision to proceed with surgery or radiotherapy often rests with the urologist. This can lead to situations where patients who might benefit from bladder-sparing treatment are not fully aware of their options.
“Clearly, the people we treat for this pathology are those who have been informed, and most of the time they found the information themselves by going to look for it because they refused the radical aspect of cystectomy,” note the radiotherapists.
Advances in Radiotherapy Technology
Modern radiotherapy techniques are becoming increasingly sophisticated. Advances in conformal and adaptive radiotherapy allow clinicians to precisely target the tumor while minimizing damage to surrounding healthy tissues. This precision reduces the risk of side effects and improves treatment effectiveness.
“Regardless, our tools have also progressed, they themselves are less invasive. Radiotherapy today is more advanced, conformal and adaptive. It targets the tumor as closely as possible, which preserves the surrounding organs, and it is modular…”
The findings from the UK study, and ongoing advancements in radiotherapy technology, reinforce the importance of offering bladder-sparing treatment as a viable option for patients with clinically node-positive bladder cancer. This approach not only provides comparable survival outcomes to surgery but also has the potential to significantly improve patients’ quality of life.
