Radical Cystectomy vs. Trimodal Therapy for Muscle-Invasive Bladder Cancer

Radical cystectomy (RC) has long been the standard of care for the management of muscle-invasive bladder cancer (MIBC). However, an increasing trend of bladder-sparing trimodal therapy (TMT) using maximal transurethral resection of bladder tumor, followed by radiation therapy (RT) with concomitant radiosensitizing chemotherapy, has been advocated.

In a recent study, researchers reported that both TMT and RC have equivalent oncology outcomes suggesting TMT as a potential alternative therapy for radical cystectomy. The study findings were published in the Journal of Clinical Oncology on February 16, 2022.

Previous randomized controlled trials (RCT) comparing bladder preservation to radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) closed early due to lack of accrual. As there is a lack of level 1 data, Dr. Alexandre R. Zlotta and his team conducted a study that provides the best evidence possible on outcomes of matched cohorts comparing trimodality therapy (TMT, maximal transurethral resection of bladder tumor followed by concurrent chemoradiation) to RC in order to guide management.

In this randomized study, the researchers included 703 patients with MIBC clinical stage T2-T3/4aN0M0 MIBC urothelial carcinoma of the bladder and matched 1 to 3, 282 patients undergoing trimodal therapy with 421 patients undergoing radical cystectomy. All patients included in this analysis had solitary tumors < 7 cm, no or unilateral hydronephrosis, and no multifocal carcinoma in situ. The primary endpoint of interest was metastasis-free survival. The analysis was performed as intent-to-treat.

Key Findings of the Study

• After propensity matching, they noted that age (71.3 vs 71.6), cT2 clinical stage (88 vs 90%), presence of hydronephrosis (12 vs 10%), and use of (neo)adjuvant chemotherapy (60 vs 65%) were similar between RC and TMT cohorts.
• They also noted salvage cystectomy was performed in 38 patients (13%) treated by TMT.
• At 5 years, they found that the metastasis-free (73 vs 78%), distant failure-free (78 vs 82%), and pelvic nodal failure-free (96 vs 94%) survival were not statistically different between RC and TMT, whereas CSS and OS favored TMT (78 vs 85%; 70 vs 78%).
• They also found that the outcomes for RC and TMT were not different among centers.
• They reported that the final pT stage in the RC patients was: pT0 14%, pT1 7%, pT2 29%, pT3/4 42% and N+ 24%.
• Peri RC mortality was 2.1% and the median number of nodes removed was 40.
• They observed that the NMIBC recurrence occurred in 57/278 (20.5%) TMT patients.

The authors concluded, "This large multi-institutional contemporary study provides the best evidence to date, in the absence of randomized trials, supporting TMT for select patients with MIBC. Oncologic outcomes seem to be equivalent between TMT and RC, affirming the position that TMT should be offered as an effective alternative."

For Further Information

DOI: 10.1200/JCO.2022.40.6_suppl.433 Journal of Clinical Oncology 40, no. 6_suppl (February 20, 2022) 433-433.