A variety of therapeutic options are available to vital, elderly patients with invasive bladder cancer, including radical cystectomy and treatments that preserve the bladder. Radical cystectomy remains the gold standard for treatment of muscle-invasive bladder cancer, but has traditionally been avoided in elderly patients because this population was thought to be at higher risk of morbidity and mortality. A growing body of evidence, however, indicates that the procedure is safe in elderly patients, and is even feasible in those at high risk. However, there still remain situations when cystectomy is not possible. In such cases curative chemo radiation it is reasonable. A neoadjuvant approach is generally supported by guidelines such as NCCN.
A meta-analysis, published in the June 6, 2003 issue of the Lancet, showed that neoadjuvant cisplatin-based chemotherapy improves 5-year survival by approximately 5% in patients with advanced bladder cancer when compared to surgery, radiation therapy, or the combination of radiation therapy and surgery. Recent studies have suggested that the combination of Gemzar® and Platinol® represents the optimal current combination for treatment of advanced or metastatic bladder cancer. Studies have also suggested that the concurrent use of radiation and chemotherapy is superior to sequential use. In many of the current studies, an attempt is made to retain the bladder in those patients who respond to neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy.Some studies use carboplatin, which has largely replaced cisplatin in various cancer types as a less toxic equivalent. This substitution is supported by many studies and by accumulated clinical experience and by NCCN.
There is not much known about second line single agent or combination chemotherapy for urothelial cancer. In the absence of conclusive data, a recent review by Yaffi says that no definitive recommendations can be put forth with regard to second-line systemic therapy. However, some evidence supports the use of cisplatin-based second-line therapy in patients who previously responded to first-line cisplatin-based therapy (more than a 6-month duration from last treatment to progression) and who are considered platinum-sensitive.
NCCN says: “No standard therapy exists in this setting, thus participation in clinical trials of new agents is recommended.
Depending on first-line treatment received, single-agent taxane or gemcitabine is preferred for palliation in this setting.
Additional palliative options include single-agent cisplatin, carboplatin, doxorubicin, 5-FU, ifosfamide, pemetrexed, methotrexate, and vinblastine”.
Chauvet B, Lagrange JL, Geoffrois L, et al. Quality-of-Life (QOL) Assessment After Concurrent Chemoradiation for Invasive Bladder Cancer. Preliminary Results of a French Multicenter Prospective Study. Proceedings of the 45th Annual Meeting of the American Society For Therapeutic Radiology and Oncology. International Journal of Radiation Oncology Biology Physics 2003;57, Number 2, Supplement, Abstract Number 88:S177.
Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. Neoadjuvant Chemotherapy in Invasive Bladder Cancer:Review and Meta-analysis. Lancet 2003;361:1927-34
Chemoradiation in bladder cancer Bull Cancer. 2005 Dec 1;92(12): 1073-7.
NCCN.ORG, Bladder cancer BL-G, 2018
F.A. Yafi, MD, S. North, MD, and W. Kassouf, MD. First- and second-line therapy for metastatic urothelial carcinoma of the bladder. Curr Oncol. Feb 2011; 18(1): e25e34.