Chemotherapy For Muscle Invasive Bladder Cancer Muscle ...

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Chemotherapy For Muscle Invasive Bladder Cancer Muscle ...

Chemotherapy For MuscleInvasive Bladder CancerDeborah Bradley, MDDuke UniversityMuscle-Invasive Disease1


Stage at Diagnosis• 75% of patients present with non-muscleinvasive disease– Managed by urologists• 25% present with muscle invasive disease atdiagnosis• Additional 10-25% will develop muscleinvasive disease with relapse from non-muscleinvasive bladder cancerWhy Do We Use Chemotherapy?• Improve outcomes in patients with localizedmuscle-invasive disease• Improve quality and quantity of life in patientswith metastatic disease2


Systemic Chemotherapy• Perioperative– Neoadjuvant• Given before surgery done with curative intent– Adjuvant• Given after surgery done with curative intent• Concurrent– Given with radiation therapy• Bladder preservation approaches• Recurrent disease (sometimes)• Palliative– Given for treatment of metastatic disease with goal ofimproving quality and quantity of lifePerioperative ChemotherapyCisplatin based combinationchemotherapy3


Surgery Alone for Muscle-Invasive Disease• 5 year survival with cystectomyDisease extentUSCMSKCCSwitzerlandN = 1054N = 686N = 507Organ confined 74% 68% 62%Extravesicular 37% 30% *49%Node positive 31% 25% 26%Neoadjuvant Chemotherapy• Advantages– Immediately treat micrometastatic disease• Cancer outside the bladder not large enough to be seen onimaging evaluation– Better tolerated before surgery– Drug delivery has been shown to be better before surgery– Information on how sensitive your tumor is tochemotherapy can be helpful to your doctor in makingfuture treatment decisions– Stronger evidence from clinical trials supporting its use4


Neoadjuvant Chemotherapy• Disadvantages– There are some patients in which neoadjuvantchemotherapy is not effective– Potential for side effects of chemotherapy to delaysurgery or result in more complications during andafter surgery• Large clinical trial testing neoadjuvant chemotherapyshowed patients did better with chemotherapy prior tosurgery with no increased complications seenAdjuvant Chemotherapy• Advantages– No risk from delaying surgery– Use the pathology results from the bladder and lymphnodes removed during surgery to select patients forchemotherapy who are at highest risk for recurrence• Disadvantages– Data from clinical trials not as strong to support thisapproach– More difficult for patients to receive chemotherapy aftersurgery with decreased drug delivery5


Palliative Chemotherapy• In vast majority of cases metastatic bladdercancer is not curable• Goal to improve quality and quantity of life• Yes, quality of life can improve withchemotherapy• Several different regimens used– GC (cisplatin or carboplatin/gemcitabine)– MVAC (rarely used now days)Options for Second Line and BeyondChemotherapy• No standard approved therapy– Vinflunine in Europe• Taxanes most common second line• Alimta used by many for third line• Clinical Trials– Targeted therapy opening at Duke for 2 nd line and beyond– Taxotere plus targeted therapy planned to open this yearat Duke for second line treatment– Phase I trials6


Questions / Open Discussion7

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