Preoperative
chemotherapy can improve survival for patients with locally advanced bladder
cancer
Preoperative chemotherapy
can improve survival for patients with locally advanced bladder cancer
compared with surgical treatment alone, according to an article in the
August 28th issue of the New England Journal of Medicine.
In the 11-year study of 307 patients, American researchers
found that patients who received preoperative chemotherapy lived an average
of 31 months longer than patients who were treated with surgery alone.
In addition, patients treated with surgery alone had a 66 percent higher
likelihood of bladder cancer-related mortality than patients who had the
combination therapy.
"This is an important advance because the study
shows a significant and clinically meaningful improvement in survival among
patients who received chemotherapy before surgery," said the study's
principal investigator, H. Barton Grossman, M.D. "Treatment of this
disease varies across the country, but we believe neoadjuvant chemotherapy
should be used more frequently to treat patients with locally advanced
bladder cancer," he added.
Bladder cancer, considered a worldwide problem, is
a leading tobacco-related cancer. In the United States, it is the fourth
most common cancer in men and the eighth most common in women. Approximately
57,000 Americans will be diagnosed with bladder cancer in 2003 and an estimated
12,500 people will die of the disease.
Because of its tendency for local and metastatic
spread, researchers have investigated a number of therapies to treat transitional
cell bladder cancer that has invaded the bladder muscle and, therefore,
is considered locally advanced. Studies to date have found that radiation
therapy before surgery did not improve outcome.
After chemotherapy proved beneficial in patients
with metastatic bladder cancer, the researchers began a randomized study
in 1987 testing survival in patients who received surgery alone versus
patients treated with 3 preoperative cycles of combination chemotherapy
with methotrexate, vinblastine, doxorubicin, and cisplatin. The study included
126 institutions around the country.
In all, 154 patients were assigned to receive surgery
as primary treatment and 153 patients received combination therapy. At
the end of the study, researchers found that median survival between the
two groups was significantly different. Patients treated with surgery lived
a median of 41 months compared to 77 months in patients treated with chemotherapy
followed by surgery.
When the investigators looked at death rates from
bladder cancer, they concluded that more patients treated with surgery
alone died of the disease, and they died at a faster rate -- 77 patients
died of bladder cancer in the surgery arm compared with 54 in the combination
treatment group. Patients treated with surgery alone had a 66 percent greater
risk of dying from bladder cancer than patients who received preoperative
chemotherapy.
When overall death rates were considered, the differences
were not as significant, Grossman said. After follow-up of more than 8
years in each group, 90 deaths occurred in the combination therapy arm
compared with 100 deaths in the surgery arm. "These patients are generally
older and may die of other causes, but the chance of surviving was higher
in the neoadjuvant group," he said.
The patients who did best were those who had no cancer
left in the bladder at the time of surgery. At the time of surgery, 38
percent of patients treated with preoperative chemotherapy had no evidence
of cancer remaining in the bladder compared with 15 percent of patients
who did not receive preoperative chemotherapy.
"There were significantly more patients in the
neoadjuvant group who had no residual disease compared to the surgery group
and those are the patients that have much better survival. The chemotherapy
effectively down-staged their cancer," noted Grossman. "Ten years
after treatment, some of those patients are still alive, so neoadjuvant
chemotherapy before surgery provided a cure for them."
|