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Can patients presenting with clinically node-positive bladder cancer without distant metastases be treated with bladder-sparing radical dose radiotherapy (RadRT) as an alternative to radical cystectomy (RC) with no negative impact on survival?

Results from a recent retrospective analysis of real-world survival outcomes in 287 patients with non-metastatic clinically node-positive bladder cancer (cN1 M0 BCa) indicate that the answer is a resounding "yes." The findings, published in the , showed that in 163 patients who underwent radical-type treatment, there was no significant difference in overall survival (OS) between the two approaches.

Patients who underwent RadRT had a median OS of 2.53 years versus 2.09 years for those treated with RC, reported Martin Swinton, MBBChir, of the Christie Hospital NHS Foundation Trust and University of Manchester in the U.K., and colleagues. Two-year OS rates were 60% in patients who received RadRT and 51% in those who underwent RC, with median progression-free survival times of 1.93 and 1.22 years, respectively.

"Our data suggest that patients who are able should undergo radical treatment and that survival outcomes are the same regardless of whether RadRT or RC is received," the authors wrote. "Given the known morbidities of RC -- in a patient group with poor survival -- this study confirms that bladder-sparing trimodal therapy should be a treatment option available to all patients with cN1 M0 BCa."

The analysis also showed that radical-type treatment was associated with improved OS compared with palliative treatment, with a median OS of 2.4 years vs 0.89 years, respectively. The data also underscored that regional lymph node involvement predicts a worse prognosis.

With a median follow-up of 4.53 years, median OS across all 287 patients included in the survival analysis was 1.55 years. There were 220 deaths, with 19% of patients achieving 5-year survival.

In the following interview, Swinton discussed the findings and the importance of providing patients with the information needed to make an informed choice about radical-type treatment options.

What impact might your findings have on the current treatment standard for patients with cN+ M0 BCa in the U.K.?

Swinton: In the U.K., all patients suitable for radical treatment see both a surgeon to discuss the option of cystectomy and an oncologist to discuss bladder preservation.

This is in accordance with 2015 from the National Institute for Health and Care Excellence or NICE. Our analysis showed that overall survival in patients with cN+M0 BCa did not differ between those who received radical cystectomy and those who received bladder preservation.

Thus, our data support NICE guidelines recommending that both treatment options be offered to all suitable cN+ M0 BCa patients.

What factors might exclude the use of RadRT in a patient with cN+ M0 BCa?

Swinton: Contraindications to RadRT include previous pelvic radiotherapy, inflammatory bowel disease, and a poor baseline bladder function.

When presented with the option of bladder preservation versus cystectomy, what percentage of patients choose which procedure?

Swinton: Among all patients with cN+M0 BC who received a radical-type treatment, 53% received bladder preservation and 47% received radical cystectomy.

Were there baseline characteristics common to patients based on treatment choice?

Swinton: The only significant difference was that on average, patients who chose radical cystectomy tended to be younger.

Did you observe any quality-of-life benefits in patients with cN+ M0 BCa treated with RadRT?

Swinton: Although we did not collect quality-of-life data in this study, the showed that patients with cN0 M0 BC receiving RC had a greater decline in body image and higher rates of male sexual problems compared with those receiving RadRT.

Comparisons of of long-term survivors of cN0 M0 BC have also noted improved body image and sexual function in RadRT patients along with higher quality-of-life scores and better bowel function. Anecdotally, we have observed that the benefits to RadRT in patients with cN+ M0 BCa are similar to those seen in the cN0 setting.

What is your take-home message for clinicians?

Swinton: Patients who present with non-metastatic clinically node-positive bladder cancers have a poor prognosis and should be counseled about the most appropriate treatment. Knowing that bladder preservation is a real alternative to radical surgery will help inform their decision-making.

What's next for your research?

Swinton: We plan to analyze data on the patterns of local and distant failure following treatment in this cN+M0 BCa cohort to determine whether there are observable differences in the site of failure depending on baseline tumor characteristics or treatment.

Read the study here.