OncoLog, Volume 57, Number 8, August 2012 Page: 2
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Preoperative Chemotherapy for Rare Bladder Cancer
[Continued from page 1]
SCUC represents less than 1%
of bladder cancers. The patients are
usually men between 60 and 80 years
old who have a history of smoking or
contact with industrial carcinogens.
Relative to other bladder cancers,
SCUC has a high potential for rapid
growth and for the development of
microscopic metastases. These charac-
teristics have made SCUC notoriously
difficult to treat.
The infrequency with which SCUC
is seen by oncologists has hampered
research progress. Studies of SCUC
have small patient sample sizes, and
research funding is small relative to
funding for more common cancers.
Thus, the publication of a long-term
retrospective study that finds SCUC
tumors to be particularly sensitive to
chemotherapy is especially noteworthy.
"The study demonstrated that neoadju-
vant chemotherapy really provides an
opportunity to cure people who other-
wise would have died of their cancer,"
said corresponding author Arlene
Siefker-Radtke, M.D., an associate
professor in the Department of Gen-
itourinary Medical Oncology.
One of the study's other notable
findings was that postoperative che-
motherapy offers little additional bene-
fit to SCUC patients undergoing initial
surgery. One reason for the discrepancy
in the benefits of neoadjuvant (pre-
operative) and adjuvant (postoperative)
chemotherapy is that patients can begin
chemotherapy much more quickly than
they can be scheduled and prepared
for surgery. While waiting for surgery,
SCUC patients who are not undergoing
chemotherapy may experience rapid
tumor growth, resulting in surgeons'
finding much more advanced disease
than clinical staging had suggested.
These patients also may develop clini-
cally evident metastatic disease during
the postoperative recovery period-
which can last 2-3 months-before
adjuvant chemotherapy begins. With
these possibilities in mind, it is perhaps
Dr. Arlene Siefker-Radtke
provides an opportuni-
ty to cure people who
otherwise would have
died of their cancer."
- Dr. Arlene Siefker-Radtke
unsurprising that patients who under-
went surgery followed by chemotherapy
had a median overall survival time of
18.1 months, which was not significant-
ly different from that of patients who
underwent surgery alone.
The benefits of neoadjuvant chemo-
therapy plus surge-y relative to both
surgery alone and surgery followed by
chemotherapy are also apparent when
one considers d-sease staging. Whereas
62% of patients treated with neoadju-
vant chemotherapy had their disease
downstaged to stage I or below at sur-
gery, only 9% of patients who under-
went initial surge-y had their disease
similarly downszaged. Patients with
lower stage tumors at surgery have a
higher likelihooc _f cure than do
patients with higher stage tumors.
Over the years. MD Anderson
physicians have been able to refine
SCUC chemotherapy regimens to
maximize their efficacy. "Initially,
we were using bladder cancer regimens
for neoadjuvant chemotherapy, but
then we'd take patients to surgery and
find we weren't achieving complete
eradication of the small-cell malignan-
cy," Dr. Siefker-Radtke said. This led
to the development of a new standard
SCUC regimen that alternates between
cycles of drugs that target small-cell
tumors, such as etoposide and cisplatin,
and those that target bladder cancer,
such as ifosfamide and doxorubicin.
In addition to varying the drug
types, oncologists must vary the num-
ber of chemotherapy cycles according
to the individual patient's needs. For
most patients, four cycles of neoadju-
vant chemotherapy will offer optimal
results. For patients with stage III or
IV cancer, doctors aim for around six
cycles to maximize the response to
Surgery and radiation therapy
Surgery for SCUC varies less than
chemotherapy. For most patients, neo-
adjuvant chemotherapy is followed by
either cystectomy or cystoprostatectomy
with a lymph node dissection. Patients
whose preoperative imaging studies
show lymph node involvement are
offered surgery only in the setting
of a major response to chemotherapy
and typically undergo a more extensive
lymph node dissection. Of the 172
patients whose cases were reviewed in
the study, 125 had surgically resectable
disease (clinical stage no higher than
It is important to bear in mind that
not all SCUC patients are good candi-
dates for the combination of neoadju-
vant chemotherapy and surgery. Patients
with poor kidney function, heart dis-
ease, or advanced emphysema may
not have the strength to undergo this
aggressive chemotherapy regimen or
the surgery that follows it. On a positive
note, neoadjuvant chemotherapy may
allow patients whose poor condition is
2 OncoLog * August 2012
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University of Texas M.D. Anderson Cancer Center. OncoLog, Volume 57, Number 8, August 2012, periodical, August 2012; Houston, Texas. (texashistory.unt.edu/ark:/67531/metapth640047/m1/2/: accessed November 12, 2018), University of North Texas Libraries, The Portal to Texas History, texashistory.unt.edu; crediting UNT Libraries Government Documents Department.