Active Surveillance After Complete Response to Chemotherapy May Be Effective in Bladder Cancer

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Many patients are cured of all disease (pT0) post-chemotherapy and may be able to defer invasive surgery if properly identified.
Many patients are cured of all disease (pT0) post-chemotherapy and may be able to defer invasive surgery if properly identified.

Active surveillance may be a viable option among patients with muscle-invasive bladder cancer (MIBC) who achieve clinical complete response (cCR) after platinum-based neoadjuvant chemotherapy (NAC), according to a study published in The Journal of Urology.1

The current standard of care for patients with MIBC is NAC followed by radical cystectomy (RC) and pelvic lymphadenectomy, but many patients are cured of all disease (pT0) post-chemotherapy and may be able to defer invasive surgery if properly identified. Considering the risks and associated comorbidities of invasive surgery, outcomes for surveillance warrants further investigation.

For this retrospective study, researchers identified 148 patients with MIBC who underwent NAC and radical transurethral resection of bladder tumor (TURBT); patients elected bladder preservation and observation instead of RC after achieving cCR. cCR was defined as being free of all disease (cT0), having negative urine cytology, and normal cross-sectional imaging. The observation regimen consisted of a physical exam, cystoscopy, and cytology every 2 to 3 months, and cross sectional CT abdominal imaging every 4 to 6 months for 2 years. The median follow up was 55 months.

The 5-year rates for disease-specific survival was 90%, overall survival (OS) was 86%, cystectomy-free survival was 76%, and recurrence-free survival was 64%.

Forty-eight percent (71) of patients had disease recurrence in the bladder; 11% (16) had muscle-invasive disease, and 37% (55) had non-invasive disease. Some patients decided to undergo salvage RC, and prevented cancer-specific death in 75% (9 of 12) and 93% (13 of 14) patients who had muscle-invasive relapse and non-invasive relapse, respectively.

The authors concluded that “despite the risks of inaccurate clinical downstaging to cT0 and muscle-invasive relapse associated with bladder preservation, these results indicate that surveillance can be safely implemented as definitive treatment in carefully selected and closely monitored cT0 MIBC patients. Future studies should validate these findings via prospective trials and improve patient selection by identifying tissue-based biomarkers predictive of invasive relapse.”

Reference

  1. Mazza P, Moran GW, Li G, et al. Conservative management following clinical complete response to neoadjuvant chemotherapy for muscle-invasive bladder cancer: contemporary outcomes of a multi-institutional cohort study [published May 19, 2018]. J Urol. doi: 10.1016/j.uro.2018.05.078

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