Radical cystectomy: still the recommended treatment?

13 April 2014

“Radical cystectomy is the treatment of choice for patients with muscle-invasive bladder cancer,” Prof. George Thalmann summarized at the end of a debate that pitted cystectomy against bladder-preserving alternatives. “Life-long bladder surveillance is necessary for all bladder-sparing protocols, because prompt salvage radical cystectomy is necessary in the case of tumour recurrence.”

A large majority of the audience in the 3000-capacity eURO Auditorium seemed to agree in a show of hands after the debate. A mere ten hands went up for alternative approaches to cystectomy. The debate on bladder preservation between Profs. Nick James (Birmingham, GB) (pro) and Jürgen Gschwend (Munich, DE) (con) was part of the second plenary session on the third day of the Congress. Prof. Thalmann (Bern, CH) moderated.

Plenary Session 2 started off a day filled with ESU courses, Thematic Sessions and Poster and Video Sessions. The Plenary Session featured state-of-the-art lectures and moderated debates on various topics concerning bladder and testis cancer.

Comparing study results
Prof. James is an oncologist from the United Kingdom where non-surgical approaches to bladder cancer have become commonplace in the past decade. He admitted to feeling like a “zebra at a lions’ party” but Thalmann reassured him that the urologists “would behave”.

James’s case provided an overview of the evidence base for bladder preservation, as well as the advantages of chemoradiotherapy, as compared to radiotherapy alone. He looked at several trials, arguing that it was metastasis that was killing patients, that a higher short-term death rate was associated with surgery, and that adjuvant chemotherapy in small doses does not significantly add to the toxicity in patients.
James concluded: “there is no convincing evidence that surgery is superior to primary bladder preservation with salvage surgery. Synchronous chemo-radiation is safe, and it improves pelvic control. Hence, it’s complementary to neoadjuvant treatment.”

Prof. Gschwend immediately referred to the EAU Guidelines in his argument for radical cystectomy. “A multimodal approach is only recommended for patients who cannot be treated surgically. In almost all other cases of muscle-invasive bladder cancer, open radical cystectomy is the treatment of choice. Delay of RC is clearly associated with reduced cause-specific survival.” Gschwend even cited James’s own study against him, although James pointed out that he’d quoted it incorrectly.

Gschwend used the figures to claim a 33% recurrence rate after radiotherapy, but James corrected him that this was not only for muscle-invasive BCa. That rate was much lower. Different spectrums of patients were also used in the studies quoted by Gschwend (including those who’d had a cystectomy for T1G3 disease, persistent CIS, poorly functioning bladders with no disease) giving a better survival rate.