Combined-modality therapy for bladder cancer.

Radical cystectomy remains standard management for patients with locally advanced T2 through T4, N0, M0 transitional cell carcinoma of the urinary bladder. Although radical cystectomy results in excellent local control, 50% or more of patients relapse. Studies have shown that multidrug cisplatin (Platinol)-based chemotherapy prolongs disease-free survival in 10% to 15% of cases and is superior to single-agent cisplatin. These studies led to the application of these regimens in conjunction with surgery and/or radiation therapy in an attempt to preserve bladder function. With this approach, the decision to leave the bladder in place, remove a portion (partial cystectomy), or perform a radical cystectomy is made after assessing the initial response to therapy. Results from neoadjuvant studies have shown that: major responses are observed in at least 50% of patients; bladder preservation can be achieved in 25% to 50%; a pathologic complete response predicts long survival; and patients with deeply invasive lesions (T3b to T4) usually are not candidates for bladder preservation. Whether overall survival is improved has been difficult to ascertain due to such issues as small sample size and case selection. Concurrently, newer surgical approaches with continent diversions have reduced, to some extent, the need for ileal conduits, a factor influencing the bladder preservation approach. Adjuvant chemotherapy, although less well studied, suggests a possible survival benefit for selected patients with a high likelihood of relapse. To optimize patients selection, new prognostic factors are necessary. Many biologic variables based on expression of tumor-related proteins are under study. Combined-modality therapy is not standard management for the majority of bladder-cancer patients. However, it is a viable alternative for those who are committed to preserving bladder function. Additional research is required to determine whether these approaches improve survival and to identify better markers of treatment outcome.