From the Guidelines
The likelihood of cure with low-dose Gemcitabine and concurrent radiation therapy for muscle-invasive bladder cancer is approximately 60-70% for localized disease, as supported by the NCCN clinical practice guidelines in oncology 1. This approach, known as bladder preservation therapy, combines radiation therapy with concurrent low-dose gemcitabine as a radiosensitizer. The treatment typically involves radiation therapy delivered over 6-7 weeks, with a total dose of 60-66 Gy, and concurrent low-dose gemcitabine, typically 50-100 mg/m² weekly.
Key Considerations
- Patients should first undergo maximal transurethral resection of the bladder tumor (TURBT) to remove all visible disease before starting chemoradiation, as recommended by the NCCN guidelines 1.
- Regular cystoscopic surveillance is essential after treatment to monitor for recurrence, with salvage cystectomy remaining an option if the cancer returns.
- Side effects of the treatment include urinary frequency, dysuria, diarrhea, and fatigue during treatment, with potential long-term bladder capacity reduction.
Treatment Details
- The treatment field should include the whole bladder and all sites of gross disease, plus or minus uninvolved regional lymph nodes, as outlined in the NCCN guidelines 1.
- Concurrent chemoradiotherapy is encouraged for added tumor cytotoxicity, and can be given without significant increased toxicity over radiation therapy alone, according to the NCCN guidelines 1.
- The use of daily image guidance is recommended when irradiating the bladder only or bladder tumor boost, to ensure accurate delivery of radiation therapy 1.
From the Research
Treatment Options for Muscle-Invasive Bladder Cancer
- The standard treatment for muscle-invasive bladder cancer (MIBC) is cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy or upfront radical cystectomy for cisplatin-ineligible patients 2.
- For patients who are ineligible for or refuse radical cystectomy, trimodal therapy with chemoradiation is offered 2.
- Neoadjuvant chemotherapy has demonstrated a survival benefit versus cystectomy alone in MIBC, with a complete pathological response (pCR) rate of 29.2% 3.
Efficacy of Gemcitabine and Cisplatin
- The combination of gemcitabine and cisplatin has shown promising results in the treatment of MIBC, with a pCR rate of 36% 3.
- A study using gemcitabine and cisplatin as neoadjuvant chemotherapy followed by selective bladder preservation chemoradiotherapy reported a 3-year metastasis-free survival (MFS) rate of 70% 4.
- However, the addition of lapatinib to gemcitabine and cisplatin as neoadjuvant therapy was limited by excessive treatment-related toxicity 5.
Low-Dose Gemcitabine and Concurrent Radiation Therapy
- There is limited information available on the use of low-dose gemcitabine and concurrent radiation therapy for MIBC.
- A study using trimodal therapy with chemoradiation, including radiation with concurrent radiosensitizing chemotherapy, reported promising results, but did not specifically mention low-dose gemcitabine 6.
- Further research is needed to determine the efficacy of low-dose gemcitabine and concurrent radiation therapy for MIBC.