The prognosis for any patient with progressive or recurrent invasive bladder cancer is generally poor. Management of recurrence depends on previous therapy, sites of recurrence, and individual patient considerations. Treatment of new superficial or locally invasive tumors that develop in the setting of previous conservative therapy for superficial bladder neoplasia has been discussed earlier in this summary.
Recurrent or progressive disease in distant sites or after definitive local therapy has an extremely poor prognosis, and clinical trials should be considered whenever possible. Patients who have not received previous chemotherapy for urothelial carcinoma should be considered for chemotherapy as described above for stage IV disease. Palliative radiation therapy should be considered for patients with symptomatic tumors.
Major drug companies continually research and develop new medications and treatments for bladder cancer that must be shown to be safe and effective before doctors can prescribe them to patients. Through clinical trials, researchers test the effects of new drugs on a group of volunteers with bladder cancer. Following a strict protocol and using carefully controlled conditions, researchers evaluate the investigational drugs under development and measure the ability of the new drug to treat bladder...
Standard treatment options for patients with recurrent bladder cancer include the following:
In patients with recurrent transitional cell carcinoma, combination chemotherapy has produced high response rates, with occasional complete responses seen.[1,2]
Evidence (combination chemotherapy):
Results from a randomized trial that compared methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) with single-agent cisplatin in patients with advanced bladder cancer show a significant advantage with MVAC in both response rate and median survival. The overall response rate with MVAC in this cooperative group trial was 39%.
Results from a randomized trial that compared MVAC with cisplatin, cyclophosphamide, and doxorubicin in 110 patients reported longer overall survival (OS) with MVAC (median survival 48.3 weeks vs. 36.1 weeks; P = .0003).
Results from a randomized trial that compared cisplatin, methotrexate, and vinblastine (CMV) with methotrexate plus vinblastine reported longer OS with CMV (median survival 7 months vs. 4.5 months; hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.41–0.73; P = .0001).
In a multicenter randomized phase III trial that compared the combination of gemcitabine plus cisplatin (GC) with the MVAC regimen in 405 patients with advanced or metastatic bladder cancer, GC yielded response rates, time-to-progression, and OS (HR, 1.04; 95% CI, 0.82–1.32; P = .75) similar to MVAC, but GC had a better safety profile and was better tolerated than MVAC. Although this study was not designed to show the equivalence of the two regimens, the similar efficacy and reduced toxic effects of GC make it a reasonable alternative in patients who may not tolerate the MVAC regimen.[Level of evidence: 1iiA]
Other chemotherapy regimens that have shown activity in metastatic bladder cancer include single-agent paclitaxel, single-agent gemcitabine, single-agent pemetrexed, carboplatin combined with either gemcitabine or paclitaxel, and gemcitabine combined with paclitaxel. There are no phase III trials demonstrating a survival or quality-of-life benefit from second-line chemotherapy.[7,8,9,10,11,12,13,14]