How To Optimally Manage Elderly Bladder Cancer Patients
Francesco Soria1,2, Marco Moschini1,3, Stephan Korn1, Shahrokh F. Shariat1,4,5
1Department of Urology, Medical University of Vienna, Vienna, Austria 2Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, 10126 Turin, Italy 3Department of Urology, Urological Research Institute, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy 4Department of Urology, University of Texas Southwestern Medical Center, Dallas, USA 5Department of Urology, Weill Cornell Medical College, New York, USA
Contributions: Conception and design: F Soria, SF Shariat Administrative support: None Provision of study materials or patients: All authors Collection and assembly of data: All authors Data analysis and interpretation: F Soria, SF Shariat Manuscript writing: All authors Final approval of manuscript: All authors.
Correspondence to:
Keywords: Bladder cancer old elderly geriatric patients radical cystectomy chemotherapy
Submitted Mar 04, 2016. Accepted for publication Mar 22, 2016.
doi: 10.21037/tau.2016.04.08
Chemotherapy Before Surgery For Muscle
For muscle-invasive bladder cancer, our doctors may recommend chemotherapy before surgery. This treatment approach is called neoadjuvant chemotherapy. Large clinical studies have shown that this method improves cure rates and long-term survival for people with muscle-invasive bladder cancer. We typically use the drugs gemcitabine and cisplatin for neoadjuvant chemotherapy.
What Type Of Chemotherapy Is Used For Bladder Cancer
Cisplatin-based chemotherapy has been the best standard treatment for bladder cancer since the 1970s. Based on the results of clinical trials from the 1990s, the two regimens most commonly used are dose-dense MVAC and GC. Chemotherapy goes into the body through a vein. It may be infused with a catheter into a vein or through a port that is placed under the skin, usually in the right side of the chest.
MVAC uses four drugs: methotrexate , vinblastine , doxorubicin , and cisplatin . We no have effective anti-nausea medication and injections that can keep immune systems from being depleted by chemotherapy. This has have improved our ability to give MVAC safely on an accelerated dose-dense schedule. The National Comprehensive Cancer Network now recommends MVAC be given according to the dose-dense or DD schedule due to improved toxicity and suggested improvement in efficacy compared with the standard schedule. Click here to view the NCCN Guidelines.
A clinical trial conducted in the late 1990s showed that the combination of gemcitabine , plus cisplatin , gives similar anticancer effects to standard MVAC combination. Both GC and DD MVAC have been useful in bladder cancer in delaying recurrence, extending life and sometimes achieving a cure, and both regimens are routinely used in the neoadjuvant and metastatic settings. Clinical trials are underway to assess whether the addition of another agent to these regimens improves outcomes.
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Median And Milestone Overall Survival
Survival results are shown in Fig. 2A-E. In all patients with mBC , the median OS from time of diagnosis was 6.4 months . The probabilities of surviving 12 and 24 months were 29.2% and 13.1% , respectively. The mOS from diagnosis was 12 months in patients treated with 1L chemotherapy and < 4 months in patients not treated with 1L chemotherapy .
Fig.2
Kaplan-Meier plots of overall survival in patients with metastatic bladder cancer. Any 1L treatment and no 1L treatment. Survival was measured from the index date. 1L cisplatin-based and non-cisplatinbased treatments. Survival was measured from the start of 1L treatment. 1L treatment with combination agents and with single agents. Survival was measured from the start of 1L treatment. 2L single-agent treatment: non-taxane and taxane based. Survival was measured from the start of 2L treatment. 2L combination treatment: non-taxane and taxane based. Survival was measured from the start of 2L treatment. 1L, first line 2L, second line. **Includes < 11 patients.
In patients who received 1L chemotherapy but not 2L chemotherapy for unknown reasons, the mOS from end of 1L chemotherapy was 2.9 months .
Radiotherapy With A Radiosensitiser
Radiotherapy is given by a machine that beams the radiation at the bladder . Sessions are usually given on a daily basis for 5 days a week over the course of 4 to 7 weeks. Each session lasts for about 10 to 15 minutes.
A medicine called a radiosensitiser should also be given alongside radiotherapy for muscle-invasive bladder cancer. This medicine affects the cells of a tumour, to enhance the effect of radiotherapy. It has a much smaller effect on normal tissue.
As well as destroying cancerous cells, radiotherapy can also damage healthy cells, which means it can cause a number of side effects. These include:
- diarrhoea
- tightening of the vagina , which can make having sex painful
- erectile dysfunction
- tiredness
- difficulty passing urine
Most of these side effects should pass a few weeks after your treatment finishes, although there’s a small chance they’ll be permanent.
Having radiotherapy directed at your pelvis usually means you’ll be infertile .
After having radiotherapy for bladder cancer, you should be offered follow-up appointments every 3 months for the first 2 years, then every 6 months for the next 2 years, and every year after that. At these appointments, your bladder will be checked using a cystoscopy.
You may also be offered CT scans of your chest, abdomen and pelvis after 6 months, 1 year and 2 years. A CT scan of your urinary tract may be offered every year for 5 years.
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Questions To Ask The Health Care Team
After you learn about your treatment options and your general health, you might need more information. Consider asking your health care team the following:
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Is my cancer curable?
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What is my chance of recovery?
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What are all of my treatment options?
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What is the goal of each treatment?
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What treatment do you recommend? Why?
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How does this treatment help me?
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What are some risks and potential side effects of this treatment?
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Will I need to be in the hospital for treatment? Or can I stay home and come to the hospital or clinic during the day?
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How long will each treatment last?
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How will this treatment affect my daily life? Will I be able to perform my usual activities?
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If I am worried about managing the costs related to my cancer care, who can help me with these concerns?
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How can I keep myself as healthy as possible during treatment?
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If I have questions or problems, who should I call?
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What support services are available to my family?
Future Directions And Research Priorities
Elderly adults with bladder cancer are faced with difficult choices with regard to the optimum management of their condition. Health-care providers need to consider the unique needs of older patients with bladder cancer. When facing any potentially catastrophic illness, issues related to functional independence and quality of life must be considered, as these factors may assume an importance equal to or even greater than that of survival. Many studies fail to include clinical outcome measures that are truly meaningful for older adults therefore, these studies are not able to appreciate the tremendous variability between individuals as they age. As the earlier discussion indicates, aging represents a very large risk factor for the development of bladder cancer, and may also increase the likelihood of muscle-invasive disease. Nevertheless, based on the available evidence, comorbidity, functional status and frailty may represent far better predictors of undesirable outcomes than chronological age alone. With these considerations in mind, future studies of elderly patients will need to incorporate these other dimensions of health status, as is normally done in the context of a geriatric assessment. Clinical domains that should be assessed include function, objective measures of physical performance, comorbidity, nutrition, social support, cognition and depression.
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Defining Elderly Patients And Life Expectancy
Although studies have found that majority of patients diagnosed with BC are elderly , who is elderly is not agreed upon. Previously, patients who were 65 years were generally considered to be part of this population but this limit is constantly pushed upwards . It is not uncommon to discuss in Toronto the postoperative course after radical cystectomy with patients who are 80 years of age whose only concern is when they will be able to resume golfing or skiing. Twenty years ago this might have looked like a joke but nowadays this is a legitimate concern in an age group who is constantly challenging and pushing further the definition of ‘elderly’.
One condition often underestimated and overlooked, is depression. We have been struck by the number of elderly patients undergoing cystectomy, smoothly recovering through their surgical postoperative course, but displayed at times severe forms of depression. We believe this aspect is often overlooked and worth additional studies.
Most studies nowadays use 75 years of age to define elderly patients . This population has been associated with many comorbidities and a shorter life expectancy . Comorbiditity and age have been found to be independent predictors of overall survival in BC patients .
With life expectancy increasing in the human population, it is important to ensure patients of all ages receive proper treatment for their disease and are not turned away due to age.
Is Combination Chemotherapy And Radiation Used For Bladder Cancer Treatment
In recent years, chemotherapy and radiation have been combined to provide a bladder preservation therapy for higher risk cases. In the past radiation therapy alone was used because it effectively shrunk tumors. Bladder cancer tumor cells are chemosensitive, susceptible to the cell-killing effects of anticancer drugs. Adding combined chemotherapy to radiation has improved results. To ensure the success of bladder preservation therapy, there are at least three requirements which should be met: 1) complete resection of the tumor by TURBT 2) no obstruction of 1 or both kidneys as a result of the bladder tumor and 3) no T4 bladder tumors.
If the tumors do not respond to an initial course of chemotherapy and radiation, it may be reasonable to perform, if medically possible, a cystectomy.
Information and services provided by the Bladder Cancer Advocacy Network are for informational purposes only. The information and services are not intended to be substitutes for professional medical advice, diagnosis, or treatment. If you are ill or suspect that you are ill, seek professional medical attention immediately! BCAN does not recommend or endorse any specific physicians, treatments, procedures, or products even though they may be mentioned on this site.
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Your Cancer Treatment Goals
Your cancer treatment goals depend on many factors. For example, the type of cancer and whether it has spread will factor into your goals.
Treatment goals include:
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Living longer, even with cancer
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Having fewer symptoms from cancer and side effects from its treatment
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Maintaining physical and emotional strength
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Having a certain quality of life
Your goals might be different from a younger persons. For example, a healthy younger person’s goal might be to cure the cancer even if treatment is very difficult. Some people are able to have aggressive treatment. This might not be true for you.
Depending on your age and general health, you might care more about feeling well than curing cancer permanently. This might be especially true if you have a chronic health condition or you feel that your quality of life is poor.
But if you are very healthy and enjoy many activities, you might want aggressive treatment. You might have plans many years in the future. If so, you might want your health care team to do everything possible for a cure.
What Are Key Issues That Affect Caring For Older People With Cancer
First, there is no reason to deny older people adequate cancer therapy surgery, chemotherapy, radiation based on age alone. Individualization is critical one size does not fit all! While one 80-year-old may tolerate a standard course of chemotherapy perfectly well, the next may not.
Add to that the fact that many older people have several health conditions for which they take multiple medications the average 75-year-old is on seven a day and the importance of personalizing care becomes even more obvious. The good news is that in 2014 there are often options available for avoiding or minimizing drug interactions. And increasingly, there are ways of treating cancer in people at varying levels of overall health and function.
Another major insight is that traditional measures of performance status that predict how well a person is likely to withstand the rigors of chemotherapy, surgery, and other forms of cancer treatment are not adequate for older patients. Instead, weve discovered that these measures, which focus on the ability to carry out daily living tasks like bathing, getting dressed, and following a medication schedule, have much greater predictive value if they are specific to the geriatric population.
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Intravesical Chemotherapy For Non
Intravesical therapies deliver a drug directly into the bladder through a catheter placed in the urethra instead of by mouth or into a vein. The drug stays in the bladder for one to two hours. Then it is drained out through the catheter or in urine. For early-stage bladder cancer, we may give intravesical chemotherapy after transurethral resection to reduce the chance that the cancer will return. We typically use the drug mitomycin for intravesical chemotherapy.
Patients 70 Years Or Older Undergoing Rc With Or Without Nac
Preweighted analysis
Subsequent analysis was focused on patients 70 years or older who underwent RC . Of these patients, only 2643 received NAC. Patients receiving NAC were more likely to be aged 70 to 80 years . NAC was associated with higher median income and high school completion rate, CCI score of 0, higher clinical T stage, and treatment at an academic center or integrated network cancer program. Furthermore, PLND and robotic surgery were more common in the NAC cohort .
Postweighted analysis
Patients receiving NAC had shorter LOS and were less likely to be readmitted within 30 days . They also had lower 30- and 90-day mortality . OS was improved with NAC .
When controlling for all other variables, NAC was a predictor of slightly lower LOS , as well as lower 30- and 90-day mortality . NAC was not associated with readmission rate. Notably, compared with the patients aged 70 to 80 years, patients 80 years had longer LOS , higher 30-day readmission rate , and higher 30- and 90-day mortality .
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What To Expect During Bcg Treatment
First, make sure you havent had any fluids for four hours before the treatment. Right before you go into the treatment room your doctor or nurse will have you empty your bladder.
Youll lie on your back, and the medical professional will insert a catheter into your urethra and into your bladder, likely using some local numbing, and use this tube to infuse the treatment.
Once the treatment is infused, your doctor or nurse will remove the catheter. Theyll have you lie on your back, each side, and your stomach for 15 minutes each. The BCG mycobacteria needs to touch the bladder cancer cells to activate the immune system. Youll then be free to go but will need to hold off on peeing for another hour.
Verywell / Alex Dos Diaz
For at least six hours after your infusion, youll need to disinfect your pee to ensure none of the mycobacteria spread to anyone else. Pour an equal amount of bleach into the toilet after you pee and let it sit for 15 minutes before flushing.
Also, people with a penis who undergo BCG treatment should avoid sex for 48 hours to ensure they dont pass the mycobacteria to their partners.
You will likely need multiple BCG treatments. They may be given weekly for a few weeks, then less often for months or years to prevent cancer from coming back.
Importance Of The Quality Of Life
The bladder cancer literature focuses on CSS and OS, providing almost no information on patients quality of life and function, which is often of greatest importance for the elderly community. Patients treated with RC, experience significant changes in urinary and sexual functions, accompanied with psychological and relationship stresses. Integrity and body image has also shown to be significantly affected . Furthermore, elderly patients are less likely to undergo neobladder reconstruction because of the higher peri-operative morbidity and mortality risks of the complex procedure, and due to the relatively high probability of functional problems requiring long-term increased care and potentially compromising the patients independence and social life. Patients older than 75 years old, treated with orthotopic neobladder were reported to have daytime and nighttime continence of only 56 and 25%, respectively, which is worse than younger populations .
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Other Treatments For Bladder Cancer
For many early-stage bladder cancers, BCG is the best option for treatment. Other treatments for bladder cancer include:
- Surgery to remove the tumor: Early cancers can be removed with TURBT surgery. More advanced cancers may require more extensive surgery, like removal of part or all of the bladder .
- Intravesical chemotherapy: This treats the inside of the bladder with chemotherapy drugs. Chemotherapy drugs commonly used for bladder cancer include Mutamycin , Gemzar , or Valstar .
- Radiation therapy
- Clinical trials
Treating Stage I Bladder Cancer
Stage I bladder cancers have grown into the connective tissue layer of the bladder wall , but have not reached the muscle layer.
Transurethral resection with fulguration is usually the first treatment for these cancers. But it’s done to help determine the extent of the cancer rather than to try to cure it. If no other treatment is given, many people will later get a new bladder cancer, which often will be more advanced. This is more likely to happen if the first cancer is high-grade .
Even if the cancer is found to be low grade , a second TURBT is often recommended several weeks later. If the doctor then feels that all of the cancer has been removed, intravesical BCG or intravesical chemo is usually given. If all of the cancer wasn’t removed, options are intravesical BCG or cystectomy .
If the cancer is high grade, if many tumors are present, or if the tumor is very large when it’s first found, radical cystectomy may be recommended.
For people who arent healthy enough for a cystectomy, radiation therapy might be an option, but the chances for cure are not as good.
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