Bladder Preservation Trial: Radiation Therapy Oncology Group 89-03
Authors: Nasir Shahab, William U. Shipley, Donald S. Kaufman
Journal: Journal of Clinical Oncology (1999)

Article Tools Correspondence Article Tools OPTIONS & TOOLS Export Citation Track Citation Add To Favorites Rights & Permissions COMPANION ARTICLES No companion articles ARTICLE CITATION DOI: 10.1200/JCO.1999.17.4.1326a Journal of Clinical Oncology - published online before print September 21, 2016 Bladder Preservation Trial: Radiation Therapy Oncology Group 89-03 Nasir ShahabxNasir ShahabSearch for articles by this author William U. ShipleyxWilliam U. ShipleySearch for articles by this author , Donald S. KaufmanxDonald S. KaufmanSearch for articles by this author Show More University of Saskatchewan, Saskatoon, Saskatchewan, CanadaMassachusetts General Hospital, Boston, MA https://doi.org/10.1200/JCO.1999.17.4.1326a First Page Full Text PDF Figures and Tables © 1999 by American Society of Clinical OncologyjcoJ Clin OncolJournal of Clinical OncologyJCO0732-183X1527-7755American Society of Clinical Oncology 041999In Reply: The main conclusion of the Radiation Therapy Oncology Group 89-03 study we reported1 was that neoadjuvant chemotherapy with methotrexate, cisplatin, and vinblastine did not improve the results achieved with a combination of cisplatin and radiation treatment in patients with muscle-invasive bladder cancer. The purpose of this phase III study was to compare two types of treatment, one of which included neoadjuvant chemotherapy, with selective bladder sparing in both arms. We believe that the results of this prospective multi-institutional trial, reporting a 49% 5-year overall survival rate and an 88% freedom from extravesical pelvic recurrence, is important for physicians and patients who are seeking information to compare the results of bladder-sparing approaches and cystectomy trials. The results of this and several other published prospective studies indicate that treatment by trimodality therapy using transurethral surgery, radiation treatment, and concurrent chemotherapy with selective bladder sparing results in as good survival as is achieved with radical cystectomy.2-4 Moreover, we have reported quality-of-life studies4,5 that indicate that the native bladder functions well after combined-modality treatment—better than any functional results that could be expected either from ileal loop urinary diversion or the best results achieved with reconstructed bladders after cystectomy. We suggest that this recent report and other reports allow this treatment to be considered a reasonable alternative to cystectomy in patients who are considered medically unfit for cystectomy or for those patients who would choose selective bladder preservation as an alternative to radical cystectomy.Shahab's main point, however, is well taken: The question of radical cystectomy versus trimodality selective bladder-sparing treatment of muscle-invasive bladder cancer can only be answered in a prospective randomized trial comparing the two approaches to treatment. His point was, in fact, a main conclusion of ours, in an earlier article on this subject.6 Unfortunately, we have found it impossible to have patients accept a randomization to bladder preservation versus radical cystectomy in a prospective trial. Patients confronted with such a choice almost unanimously reject immediate radical cystectomy with its deleterious effect on the quality of life and choose the selective bladder-sparing approach. Rather than agree with Shahab that offering bladder sparing gives a “false impression to practicing oncologists that concurrent cisplatin-radiation therapy is equal to cystectomy,” we suggest that offering potential bladder sparing, either in the context of a clinical trial or as an alternative to radical cystectomy, provides important hope for carefully selected patients. Cystectomy is, of course, preserved as an option for those patients who fail to achieve a complete response to chemoradiation, and our results and other reports support that this delay in cystectomy does not lead to higher distant or pelvic failure rates. 1. Martinez-Pineiro JA, Martin MG, Arocena NF, et al: Neoadjuvant cisplatin chemotherapy before radical cystectomy in invasive transitional cell carcinoma of the bladder: A prospective randomized phase III study. J Urol 153::964,1995-973, Crossref, Medline, Google Scholar2. Malmstrom PU, Rintala E, Wahlquist R, et al: Five-year followup of a prospective trial of radical cystectomy and neoadjuvant chemotherapy: Nordic Cystectomy Trial I—The Nordic Cooperative Bladder Cancer Study Group. J Urol 155::1903,1996-1906, Crossref, Medline, Google Scholar3. Shipley WU, Zietman AL, Kaufman DS, et al: Invasive bladder cancer: Treatment strategies using transurethral surgery, chemotherapy and radiation therapy with selection for bladder conservation. Int J Radiat Oncol Biol Phys 39::937,1997-943, Crossref, Medline, Google Scholar4. Kachnic LA, Shipley WU, Griffin PP, et al: Combined modality treatment with bladder conservation for invasive bladder cancer: Long-term tolerance in the female patient. Cancer J Sci Am 2::79,1996-84, Medline, Google Scholar5. Kaufman DS, Shipley WU, Griffin PP, et al: Selective bladder preservation by combination treatment of invasive bladder cancer. N Engl J Med 329::1377,1993-1382, Crossref, Medline, Google Scholar