Radiation Oncology/Bladder/Superficial

Superficial Bladder Cancer (Ta, Tis, T1)

Treatment Overview

 * 80% of bladder cancers are superficial
 * 50-70% of these patients will have a recurrence after their initial treatment, though this depends on grade:
 * Low grade (Ta, T1G1-2): 50% recurrence rate, and 5% rate of T2+ progression
 * High grade (T1G3): 70% recurrence rate, and 30% rate of T2+ progression
 * <5% will develop metastatic disease without first developing T2+ progression
 * High risk of progression:
 * Multifocal Tis or Tis associated with Ta or T1
 * Multiple tumors
 * Grade 3
 * Positive urine cytology
 * Dysplasia in multiple random biopsies
 * Rapid recurrence following TURBT
 * Majority of tumors occuring at separate sites or recurrences are from the same clone
 * Goal of treatment is to 1) prevent recurrence and 2) prevent progression to muscle-invasive disease
 * Patients who progress to T2+ disease have equally poor outcomes as those who present with T2+ disease
 * Thus, for superficial cancers at high risk of progession, ~30% will progress and half of these (~15%) will die of their disease
 * Adjuvant intravesical therapy may be helpful in the short term (2 years), though recurrence rate in the long term (5 years) comparable to no treatment

Treatment algorithm (from NCCN guidelines, v1.2005) Perform TURBT:
 * Tis: BCG
 * cTa, G1-2: may observe or consider single dose intravesical chemotherapy (not BCG)
 * cTa, G3 or cT1, G1-2: observe or intravesical BCG or mitomycin
 * cT1, G3: BCG or consider cystectomy. Re-resect if not completely resected.

Follow-up after treatment:
 * Cystoscopy + urine cytology every 3 months x 2 yrs, then q6m x 2 yrs, then annually

Treatment of recurrence: intravesical BCG (Bacillus Calmette-Guerin) or intravesical chemo

Role of Radiation

 * At present, there is no benefit for adjuvant RT after TURBT


 * MRC T1 Bladder (1991-2003) -- observation/intravesical therapy vs EBRT after TURBT
 * Randomized, 2 strata. 210 patients with pT1G3 TCC after TURBT. Goal: prevention of progression to T2 and subsequent disease fatality
 * Unifocal disease and no Tis: Arm 1) observation vs. Arm 2) RT 60/30 to bladder only
 * Multifocal disease and/or Tis: Arm 1) intravesical therapy (MMC or BCG) vs. Arm 2) RT 60/30 to bladder only
 * 2007 PMID 17631326 -- "A randomized trial of radical radiotherapy for the management of pT1G3 NXM0 transitional cell carcinoma of the bladder." (Harland SJ, J Urol. 2007 Sep;178(3 Pt 1):807-13; discussion 813. Epub 2007 Jul 16.)
 * Outcome: Progressive disease 32%. 5-year PFS control 52% vs RT 41% (NS). Cancer-related death 16%. No difference in OS, or cystectomy rate (~15%)
 * Conclusion: No evidence that adjuvant RT is better than more conservative treatment; prognosis poor regardless