Bladder Cancer: Current Optimal Intravesical Treatment
Bladder Cancer: Current Optimal Intravesical Treatment
Superficial bladder cancer can be treated surgically, but patients are at high risk for recurrence. Tumors are categorized as low, intermediate, and high-risk based on grade, stage, and pattern of recurrence. Low-risk tumors are best treated with a single instillation of chemotherapy (thiotepa, doxorubicin, or mitomycin) (Lamm, 2002). Though effective, the toxicity of bacillus Calmette-Guerin immunotherapy (BCG) restricts its use to treat higher-grade tumors. Intermediate risk tumors can be treated with chemotherapy as well, but will often require immunotherapy. High-risk tumors are best treated with intravesical BCG using a 3-week maintenance schedule. Side effects of BCG immunotherapy can be decreased by logarithmic reductions in dose. Patients who fail BCG may be rescued with BCG plus interferon alfa or radical cystectomy.
Bladder cancer is more common than generally appreciated; 62,240 new cases and 12,710 deaths were expected in the United States in 2004 (Jemal et al., 2004). Patients typically present with either microscopic or gross hematuria. Bleeding from a bladder tumor is generally intermittent. Therefore resolution, either spontaneously or after antibiotic treatment for presumed bladder infection, does not reduce the need for urologic evaluation. Diagnostic studies most commonly used are intravenous urography, urine cytology, and cystoscopy. Fortunately, about 80% of patients present with superficial disease that can be successfully treated surgically (Lamm, Griffith, Pettit, & Nseyo, 1992). Effective treatment plans can lead to high survival rates. The goals of treatment are (a) reduce tumor recurrence, (b) lower the risk of disease progression, and (c) improve survival. Preventing progression to muscle-invasive disease is key, because only 50% of these patients will survive 5 years even with aggressive surgery (cystectomy) (Dalbagni et al., 2001). Prognosis, as noted later, is also highly dependent on grade.
Historically, two-thirds of patients have tumor recurrence within 5 years, and nearly 90% have recurrence by 15 years (Lamm & Griffith, 1992). Two factors best predict recurrence: (a) history of previous recurrence, particularly if within 3 months, and (b) the presence of multiple tumors. Solitary tumors recurred in 51% of patients, while those with recurrent tumors or multiple tumors had recurrence rates of 91% (Heney, 1992). As few as 20% of patients who are disease-free at 3 months will have tumor recurrence within 5 years. Invasion of the stroma (lamina propria) increases the risk of invasion into the bladder muscle from 4% to 30% (Vicente, Laguna, Duarte, Algaba, & Chechile, 1991). High-grade tumors have a significantly worse prognosis. In the National Bladder Cancer Group study, only 2% of patients with low-grade (grade I Stage Ta) tumors had progression to muscle invasion, compared with 48% of patients with high-grade (grade III Stage T1) tumors. The presence of carcinoma in situ (CIS) significantly worsens the prognosis of high-grade disease, increasing progression risk from 10% to 65% in one study (Bostwick, 1992). The best predictor of death from superficial bladder cancer is the presence of high-grade disease. Mortality for low-grade tumors was 6% compared with 21% for high-grade tumors (Heney, 1992).
The European Organization for Research and Treatment of Cancer (EORTC) divided superficial bladder cancer patients into low, intermediate, and high-risk groups based on their experience with thousands of patients enrolled in prospective studies. The authors' experience corroborates that low-risk patients are those with solitary grade I Stage Ta tumors; intermediate-risk patients are those with multiple or recurrent grade I Stage Ta tumors, or grade II Ta tumor(s) (single or multiple); high-risk patients are those with one or more of the following: grade III disease (high-grade, in the new terminology), lamina propria (T1) invasive disease, CIS, or recurrence at 3 months.
Superficial bladder cancer can be treated surgically, but patients are at high risk for recurrence. Tumors are categorized as low, intermediate, and high-risk based on grade, stage, and pattern of recurrence. Low-risk tumors are best treated with a single instillation of chemotherapy (thiotepa, doxorubicin, or mitomycin) (Lamm, 2002). Though effective, the toxicity of bacillus Calmette-Guerin immunotherapy (BCG) restricts its use to treat higher-grade tumors. Intermediate risk tumors can be treated with chemotherapy as well, but will often require immunotherapy. High-risk tumors are best treated with intravesical BCG using a 3-week maintenance schedule. Side effects of BCG immunotherapy can be decreased by logarithmic reductions in dose. Patients who fail BCG may be rescued with BCG plus interferon alfa or radical cystectomy.
Bladder cancer is more common than generally appreciated; 62,240 new cases and 12,710 deaths were expected in the United States in 2004 (Jemal et al., 2004). Patients typically present with either microscopic or gross hematuria. Bleeding from a bladder tumor is generally intermittent. Therefore resolution, either spontaneously or after antibiotic treatment for presumed bladder infection, does not reduce the need for urologic evaluation. Diagnostic studies most commonly used are intravenous urography, urine cytology, and cystoscopy. Fortunately, about 80% of patients present with superficial disease that can be successfully treated surgically (Lamm, Griffith, Pettit, & Nseyo, 1992). Effective treatment plans can lead to high survival rates. The goals of treatment are (a) reduce tumor recurrence, (b) lower the risk of disease progression, and (c) improve survival. Preventing progression to muscle-invasive disease is key, because only 50% of these patients will survive 5 years even with aggressive surgery (cystectomy) (Dalbagni et al., 2001). Prognosis, as noted later, is also highly dependent on grade.
Historically, two-thirds of patients have tumor recurrence within 5 years, and nearly 90% have recurrence by 15 years (Lamm & Griffith, 1992). Two factors best predict recurrence: (a) history of previous recurrence, particularly if within 3 months, and (b) the presence of multiple tumors. Solitary tumors recurred in 51% of patients, while those with recurrent tumors or multiple tumors had recurrence rates of 91% (Heney, 1992). As few as 20% of patients who are disease-free at 3 months will have tumor recurrence within 5 years. Invasion of the stroma (lamina propria) increases the risk of invasion into the bladder muscle from 4% to 30% (Vicente, Laguna, Duarte, Algaba, & Chechile, 1991). High-grade tumors have a significantly worse prognosis. In the National Bladder Cancer Group study, only 2% of patients with low-grade (grade I Stage Ta) tumors had progression to muscle invasion, compared with 48% of patients with high-grade (grade III Stage T1) tumors. The presence of carcinoma in situ (CIS) significantly worsens the prognosis of high-grade disease, increasing progression risk from 10% to 65% in one study (Bostwick, 1992). The best predictor of death from superficial bladder cancer is the presence of high-grade disease. Mortality for low-grade tumors was 6% compared with 21% for high-grade tumors (Heney, 1992).
The European Organization for Research and Treatment of Cancer (EORTC) divided superficial bladder cancer patients into low, intermediate, and high-risk groups based on their experience with thousands of patients enrolled in prospective studies. The authors' experience corroborates that low-risk patients are those with solitary grade I Stage Ta tumors; intermediate-risk patients are those with multiple or recurrent grade I Stage Ta tumors, or grade II Ta tumor(s) (single or multiple); high-risk patients are those with one or more of the following: grade III disease (high-grade, in the new terminology), lamina propria (T1) invasive disease, CIS, or recurrence at 3 months.
Source...