Current status of radiation therapy and combined-modality treatment for bladder cancer

Standard treatment for muscle-invasive bladder cancer is radical cystectomy. Combined-modality treatment (CMT), including transurethral resection (TURBT), radiation therapy (RT) and systemic chemotherapy, has been shown to produce survival rates comparable to those of radical cystectomy. With these programs, cystectomy has been reserved for patients with incomplete response or local relapse after trimodality treatment.

This review summarizes series of radical RT with different fractionation schedules and focuses on CMT for muscle-invasive bladder cancer. Current protocols of the bladder-sparing approach will be discussed and the background of future developments, including incorporation of promising new chemotherapeutic agents as well as the role of predictive and prognostic factors in selecting patients for the respective treatment alternatives, will be given.

There is moderate evidence that hyperfractionated and accelerated regimens are superior to conventional RT at least in situations where no concomitant chemotherapy is applied. Several phase II studies and one phase III study indicate that concomitant radiochemotherapy is superior to RT alone. In modern series of CMT, 5-year survival rates in the range of 50-60% have been published, and about three quarters of the surviving patients maintained their own bladder. Recent data suggest that incorporation of newer chemotherapeutic agents, particularly gemcitabine and taxanes, in CMT protocols is feasible and promising. Clinical criteria helpful in determining patients for bladder preservation include such variables as early tumor stage, unifocal tumor, a visibly and microscopically complete TURBT, and absence of ureteral obstruction.

CMT for bladder cancer is a reasonable treatment option for patients who are deemed medically unfit for cystectomy and for those seeking an alternative to radical cystectomy.