Ask the Doctor

Summer 2006

We thank Walter Stadler, MD, FACP, Professor and Director of Genitourinary Oncology at the University of Chicago, for answering our questions for this issue of BCAN Outlook.

Q. What are the most important things for a person with metastatic bladder cancer to know?

A. It is important for people with metastatic bladder cancer (bladder cancer that has spread to other parts of the body)to be aware of the best treatment options available to help fight this disease. Currently, there are two chemotherapy regimes that have become the standards of care for metastatic bladder cancer— MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) or gemcitabine/cisplatin.

Because cisplatin may be difficult to administer in patients with abnormal renal function, carboplatin based therapy can be considered, but the data strongly suggest that carboplatin is inferior to cisplatin. As a reasonable alternative to account for renal insufficiency and still provide maximal benefit, some have considered the combination of gemcitabine, carboplatin, and paclitaxel, however, at this time there is no phase III data to validate efficacy.

Because patients with organ metastases, symptoms from their metastatic cancer, or anemia as a result of their cancer do more poorly, participation in a clinical trial should always be considered. For patients who suffer from progressive cancer following initial therapy, there is no good standard care and participation in a clinical trial should be strongly considered.

Q. What is the difference between neo-adjudvant chemotherapy and adjudvant chemotherapy? Is there an advantage to one over the other?

A. Neoadjuvant chemotherapy is administered prior to surgery for muscle invasive bladder cancer. Completed phase III trials show that cisplatin based multi-agent chemotherapy (generally MVAC, but gemcitabine/cisplatin is a reasonable alternative) improve survival when administered in this manner.

Adjuvant chemotherapy is administered after surgery. The agents probably work just as well, but the completed trials are too small to definitively prove this. The disadvantage of adjuvant therapy is that chemotherapy following major surgery is harder to tolerate than it is prior to surgery. The advantage of adjuvant therapy is that complete pathologic staging information (available only after surgery) provides better information regarding prognosis, which can better inform the patient and the doctor on the relative value of chemotherapy.

In other words, if the risk of recurrence of bladder cancer based on complete pathologic information is very high, a relatively modest chemotherapy benefit (e.g. a 10% improvement) will lead to a very large absolute benefit. However, the absolute benefit of chemotherapy is much lower when the overall risk of recurrence is less.