br Conflict of interest br Introduction Bladder
Conflict of interest
Introduction Bladder cancer is one of the most common cancers in the world. It is estimated that around 74,000 new cases of HG-9-91-01 Supplier cancer and 16,000 bladder cancer-related deaths will occur in the United States in 2015. It is prominent in men and in the elderly population. In Taiwan, 2199 new cases of bladder cancer were reported in 2011. The median age at diagnosis was 71 years. Radical cystectomy with pelvic lymph node dissection is the standard treatment for muscle-invasive bladder cancer (MIBC). Bladder-preserving approaches, including transurethral resection of the bladder tumor (TURBT) followed by chemotherapy, radiotherapy, or a combination of chemotherapy and radiotherapy are alternatively strategies for patients unfit for radical cystectomy or for elderly patients with increased risks of morbidity or mortality. Radiotherapy is commonly used to treat MIBC, but radiotherapy alone is inferior to radical cystectomy and combinations of concurrent radiosensitizing chemotherapy. Although concurrent chemoradiotherapy (CCRT) provides a survival benefit and allows bladder preservation, CCRT in the elderly population is usually underused. In Taiwan, only 6–7% of MIBC patients aged >70 received CCRT. In addition, the use of gemcitabine as radiosensitizing agent is rarely discussed.
Patients and methods
Discussion Treating elderly patients with MIBC can be challenging, but aggressive treatment of bladder cancer may improve survival in the elderly population. Radical cystectomy is still the standard treatment for MIBC. Alternative options include partial cystectomy and bladder preservation approaches. However, elderly patients and their physicians may be concerned about the mortality and morbidity associated with surgery, and other aspects of treatment, including organ preservation, quality of life, and the physical condition needed for tolerating treatment-related toxicity. Curative therapy, including cystectomy and aggressive bladder-preserving therapies for non-cystectomy patients, is underused in the elderly population. Radical cystectomy with pelvic lymph node dissection is often performed on healthy young patients with MIBC. In a series of 1054 patients, the overall recurrence-free survival at five and 10 years for the entire cohort was 68% and 66%, respectively. Generally, 2.5% of the patients faced perioperative deaths and 28% of the patients had early complications. Recently, Leveridge and colleagues conducted a retrospective study involving 3320 patients with age stratified as <70, 70–74, 75–79 and ≥80 years, with the five-year overall survival at 40%, 34%, 28% and 23%, respectively. It is not surprising that early mortality increased with age due to decline of functional reserves and loss of homeostasis. Overall, the early perioperative mortality in the elderly population was up to 9.5% at 30 days and 11% at 90 days. In addition, patients treated with radical cystectomy may have to sacrifice their quality of life. Radiotherapy with concurrent chemotherapy after complete TURBT is equivalent to radical cystectomy and more effective than radiotherapy alone after TURBT. In general, pooled analyses showed the five-year overall survival rate to be around 60%. Turgeon et al further reviewed the outcomes of CCRT after TURBT in patients aged ≧65 with MIBC. The two-year and three-year overall survival rates were between 33% and 93% and between 34% and 88%, respectively. In our study, the respective two-year and three-year overall survival rates were 74% and 60%. In contrast to the relatively high perioperative mortality or early complications of radical cystectomy, CCRT toxicity after TURBT is more tolerable for non-surgical candidates. Grade 3–4 acute toxicity was reported in up to 43% of elderly patients. Compared with earlier data, the most prominent acute toxicity we observed was neutropenia (grade 3–4, 44%). Otherwise, the majority of our patients withstood the entire treatment process. One patient withdrew from chemotherapy and another two patients were hospitalized due to acute toxicity. While our patients were highly selected, our observations reflect the reality that patients and physicians chose CCRT after TURBT because of the low treatment-related mortality.