Nonsurgical Treatment for Bladder Cancer That Has Spread to Lymph Nodes

Bladder cancer is common worldwide. An important part of its treatment is radical cystectomy , surgery to remove the bladder and surrounding lymph nodes. This is the standard treatment when cancer has spread into the bladder muscle or nearby lymph nodes but has not developed metastases in distant tissues or organs (see Bladder Cancer Treatment by Stage). However, the procedure can affect quality of life and cause serious side effects. Researching "less invasive" bladder-preserving treatment options may therefore improve quality of life and treatment outcomes.

Below, muscle-invasive bladder cancer is shown.

A new study compares bladder-preserving trimodal treatment with radical cystectomy in terms of effectiveness.

What Is Trimodal Treatment?

Trimodal treatment is a combined approach to treating bladder cancer, with the following three main components:

1. Maximal Transurethral Resection (TURBT): Endoscopic removal of the tumor from the bladder. This procedure allows complete tumor removal and accurate pathological staging.
2. Radiotherapy: A treatment that uses high doses of radiation to kill cancer cells or stop their growth. In bladder cancer, radiation is delivered directly to the tumor area.
3. Chemotherapy: Chemotherapy drugs increase the effectiveness of radiotherapy. They are given concurrently with radiation and enhance its effects on cancer cells.

Trimodal treatment aims to preserve the bladder and is considered an alternative to radical cystectomy (complete bladder removal). It may be a preferred option, particularly for patients who are unfit for surgery or wish to retain their bladder.

Trimodal Treatment and Radical Cystectomy: Study Details

• The study retrospectively analyzed data from 287 patients with clinically node-positive, nonmetastatic (cN1, M0) bladder cancer between 2012 and 2021.
• It was published on July 21, 2023 in the Journal of Clinical Oncology .
• Patients were treated at four UK centers offering both trimodal therapy and radical cystectomy.
• The main outcome measures were overall and progression-free survival.

Study Findings and Results

• For all patients:
  • Median overall survival was 1.55 years. Overall survival rates at 2 and 5 years were 39% and 19%, respectively.
  • Median progression-free survival was 0.95 years. The 2- and 5-year rates were 28% and 17%, respectively.
• 163 patients received radical treatment (surgery or a trimodal approach), while 124 received palliative treatment .
• Radical treatment was associated with better overall survival (median 2.4 versus 0.89 years) and progression-free survival (median 1.5 versus 0.63 years).
• Among those receiving radical treatment, 87 underwent radical-dose radiotherapy (trimodal treatment) and 76 underwent radical cystectomy. In multivariable analysis, the choice of radical treatment had no significant effect on survival outcomes. Results were therefore similar whether patients underwent surgery or trimodal treatment.
  • Median overall survival was 2.53 years with the trimodal approach versus 2.09 years with radical cystectomy (HR = 0.94, 95% confidence interval = 0.63–1.41, P = 0.76).
  • The 2-year survival rates were 60% and 51%, respectively.
  • Median progression-free survival was 1.93 years with radical-dose radiotherapy versus 1.22 years with radical cystectomy (HR = 0.74, 95% confidence interval = 0.50–1.08, P = 0.12).
  • These findings appear to favor trimodal treatment, although the differences were not statistically significant. 

Conclusion and Commentary

These findings suggest that trimodal treatment may be a potential alternative in bladder cancer care.

More specifically, this multicenter retrospective analysis assessed real-world outcomes for patients with clinically node-positive bladder cancer. It found no difference in overall or progression-free survival between radical cystectomy and trimodal treatment. The analysis provides evidence that lymph node involvement around the bladder should not be considered a contraindication to trimodal treatment.

Although this possibility was not addressed within the scope of the present study, adding immunotherapies , which we know are effective in bladder cancer, to trimodal treatment in the future may further improve survival outcomes.