When bladder cancer is diagnosed by a doctor, it often has already invaded the muscular wall of the bladder. Currently the standard treatment is to remove the bladder.

But that may no longer be necessary with newer methods of treatment, according to new reports in leading cancer journals.

William U. Shipley, MD, and colleagues from the Massachusetts General Hospital in Boston, have long been advocates of preserving the bladder when appropriate in cases of locally advanced bladder cancer.

In the journal Urology (Vol. 60: 62-68), Shipley and his team reviewed their experience with 190 patients treated from 1986 through 1997. All of them had bladder cancer which had invaded the muscular wall of the bladder.

Patients were treated by removal of as much of the bladder tumor as possible by a procedure called transurethral resection of the bladder tumor.

In this procedure, a tube called a cystoscope is passed through the urethra (urine travels through this passage as it leaves the body). Then, the doctor removes the bladder tumors using instruments passed through the cystoscope.

In this study, a combination of radiation therapy and chemotherapy was followed by transurethral resection.

If patients did not have a complete response to this treatment, they were advised to have surgery to remove their bladder at that time. Similar advice was given to patients whose tumors recurred. All patients were followed carefully after their treatment.

In this study, 121 patients had a complete response to the multiple treatments. Of these, 72 never had their cancer come back. Another 22 patients who had their disease relapse were once again put into remission and avoided cystectomy.

More than one half of the patients who started the study (94) did not require removal of the bladder, which would have previously been the standard therapy.

According to the authors, for those patients whose bladders were not removed, "The 10-year overall survival and disease-specific survival rates are comparable to the results reported with contemporary radical cystectomy for patients of similar clinical and pathologic stage."

Sixty-six of the patients had a cystectomy, either early in their treatment when they did not respond to the chemotherapy and radiation therapy, or later when their cancer recurred.

James E. Montie, MD, from the University of Michigan School of Medicine, Ann Arbor, who commented on the study in Urology said, "Frankly, most urologists have not embraced bladder preservation as a viable treatment option, citing the possible risk of a greater number of deaths, extent of treatment needed, and improved rehabilitation that may be possible with neobladders and nerve-sparing cystectomies."

But Montie said that because some patients do well with bladder preservation, doctors are challenged to identify patients who would benefit from this type of procedure.

A report in a second journal, by Claus Rödel, MD, and colleagues from the University of Erlangen in Germany, recounted these doctors' experience with bladder preservation. Their study appeared in the Journal of Clinical Oncology (JCO, Vol. 20, No. 14: 3061-3071).

Rödel points out that organ-sparing treatment has become the standard of care for many cancers including breast cancer, anal cancer, and soft tissue sarcoma among others.

Rödel wanted to know if this could apply to bladder cancer. Based on 18 years of experience at his hospital, in treating 415 patients, his group said it is a reasonable option for patients who are properly selected for the treatment.

These doctors reported that almost seven out of 10 patients with bladder cancer that they treated with transurethral resection, chemotherapy, and radiation therapy had complete disappearance of their cancer.

Of the 288 patients, almost two out of three had no recurrence of their disease. Of the 102 who recurred, 42 had their bladders removed.

For the patients who did not have a complete response to their first treatments, a cystectomy was performed.

Survival was again comparable to studies where the bladder was removed.

But, the authors caution that patients have to be carefully selected for this type of treatment. Factors include an early stage cancer and the complete removal of all visible cancer at the time of the transurethral resection.

The authors also underlined the importance of continued follow-up, even beyond 10 years following surgery. This is because survivors remain at risk for developing recurrences after the 10-year mark.

An editorial in the same issue of the JCO (3048-3050) by Mary Gospodarowicz, MD, from the Princess Margaret Hospital in Toronto, Ontario, agreed that it is important for urologists, radiation oncologists, and medical oncologists to work together to provide patients with options.

"These results certainly offer hope and indeed opportunity for bladder preservation in a significant proportion of patients who currently undergo cystectomy," she said.

"Unless urologists, radiation oncologists, and medical oncologists decide to collaborate and further optimize bladder conserving approaches," Gospodarowicz said, "cystectomy may remain as the only option for patients with muscle invasive bladder cancer, regardless of the prospects for organ preservation."