title: Long-term Outcomes After Bladder-preserving Tri-modality Therapy for Patients with Muscle-invasive Bladder Cancer: An Updated Analysis of the Massachusetts General Hospital Experience.
abstract: Tri-modality therapy (TMT) is a recognized treatment strategy for selected patients with muscle-invasive bladder cancer (MIBC).
  
  
  
  Report long-term outcomes of patients with MIBC treated by TMT.
  
  
  
  Four hundred and seventy-five patients with cT2-T4a MIBC were enrolled on protocols or treated as per protocol at the Massachusetts General Hospital between 1986 and 2013.
  
  
  
  Patients underwent transurethral resection of bladder tumor followed by concurrent radiation and chemotherapy. Patients with less than a complete response (CR) to chemoradiation or with an invasive recurrence were recommended to undergo salvage radical cystectomy.
  
  
  
  Disease-specific survival (DSS) and overall survival (OS) were calculated using the Kaplan-Meier method.
  
  
  
  Median follow-up for surviving patients was 7.21 yr. Five- and 10-yr DSS rates were 66% and 59%, respectively. Five- and 10-yr OS rates were 57% and 39%, respectively. The risk of salvage cystectomy at 5 yr was 29%. In multivariate analyses, T2 disease (OS hazard ratio [HR]: 0.57, 95% confidence interval [CI]: 0.44-0.75, DSS HR: 0.51, 95% CI: 0.36-0.73), CR to chemoradiation (OS HR: 0.61, 95% CI: 0.46-0.81, DSS HR: 0.49, 95% CI: 0.34-0.71), and presence of tumor-associated carcinoma in situ (OS HR: 1.56, 95% CI: 1.17-2.08, DSS HR: 1.50, 95% CI: 1.03-2.17) were significant predictors for OS and DSS. When evaluating our cohort over treatment eras, rates of CR improved from 66% to 88% and 5-yr DSS improved from 60% to 84% during the eras of 1986-1995 to 2005-2013, while the 5-yr risk of salvage radical cystectomy rate decreased from 42% to 16%.
  
  
  
  These data demonstrate high rates of CR and bladder preservation in patients receiving TMT, and confirm DSS rates similar to modern cystectomy series. Contemporary results are particularly encouraging, and therefore TMT should be discussed and offered as a treatment option for selected patients.
  
  
  
  Tri-modality therapy is an alternative to radical cystectomy for patients with muscle-invasive bladder cancer, and is associated with comparable long-term survival and high rates of bladder preservation.
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA; Harvard Radiation Oncology Program, Boston, MA, USA.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Giacalone
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: William U
authors.initials: WU
authors.lastname: Shipley
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Rebecca H
authors.initials: RH
authors.lastname: Clayman
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Andrzej
authors.initials: A
authors.lastname: Niemierko
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Drumm
authors.affiliation: Department of Urology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Niall M
authors.initials: NM
authors.lastname: Heney
authors.affiliation: Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Marc D
authors.initials: MD
authors.lastname: Michaelson
authors.affiliation: Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Lee
authors.affiliation: Division of Hematology-Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Saylor
authors.affiliation: Department of Urology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Matthew F
authors.initials: MF
authors.lastname: Wszolek
authors.affiliation: Department of Urology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Adam S
authors.initials: AS
authors.lastname: Feldman
authors.affiliation: Department of Urology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Douglas M
authors.initials: DM
authors.lastname: Dahl
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Zietman
authors.affiliation: Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA. Electronic address: jefstathiou@partners.org.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Efstathiou
mesh_terms: D000368:Aged; D001900:Boston; D002277:Carcinoma / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D059186:Chemoradiotherapy, Adjuvant / Q000009:adverse effects / Q000401:mortality; D015653:Cystectomy / Q000009:adverse effects / Q000379:methods / Q000401:mortality; D018572:Disease-Free Survival; D006769:Hospitals, General; D006801:Humans; D053208:Kaplan-Meier Estimate; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D059351:Organ Sparing Treatments / Q000009:adverse effects / Q000379:methods / Q000401:mortality; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D017741:Survivors; D013997:Time Factors; D016896:Treatment Outcome; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*
keywords: Bladder cancer; Chemotherapy; Radiation therapy; Tri-modality therapy