Clinical Oncology(1992) 4:273-274 © 1992The RoyalCollegeof Radiologists

Clinical Oncology

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2 I, OCT 92

Editorial

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How Should We Palliate Bladder Cancer? A. Lydon and G. M. Duchesne Meyerstein Institute of Clinical Oncology, Middlesex Hospital, Mortimer Street, London W1N 8AA, UK

Bladder carcinoma is one of the most common malignancies in developed countries. In the United Kingdom alone it accounts for 9000-10 000 new cases of malignancy each year [1], of which 20%-30% have muscle infiltration at presentation and require treatment extending beyond intravesical manoeuvres alone. A significant proportion of these patients are elderly, and frequently suffer from concomitant conditions, especially those which are tobacco related such as ischaemic heart disease and chronic obstructive airways disease, which may limit their life expectancy quite apart from their cancer. In addition, a number of patients will be judged to have tumour too far advanced (T4, node positive or distant metastasis) to consider curative treatment. Persistent symptoms such as haematuria, urinary frequency and dysuria are nonetheless present in over 80% of patients despite transurethral tumour debulking. These patients are therefore usually referred to the radiotherapist for management, but it is inappropriate to treat them with a prolonged course of radiotherapy with a high incidence (50%-90%) [2] of acute side effects, It is remarkable how few publications have examined whether or not radiotherapy is effective palliative treatment in these patients or what the optimal radiation schedule should be to achieve symptom relief without causing toxicity. One general review of the management of bladder cancer in the 'geriatric' population (those over the age of 70) recognizes that radiotherapy may be an appropriate treatment modality, but does not address the question of how best it might be employed in this group considered to be poor surgical risks or incurable [3]. A large retrospective survey of patients over 80 years of age compared the results of radical radiotherapy of 45-55 Gy with those after 30 Gy given with palliative intent [4]. The authors noted that only 9 of 33 patients with T4 tumours were considered suitable for even palliative radiotherapy and that their survival was, not surprisingly, significantly shorter than those treated with radical intent, and only marginally longer than those who were untreated. Nowhere is comment made on whether or not symptomatic relief was obtained, the sine qua non of palliation. Correspondence and offprint requests to: Dr G. M. Duchesne, Senior Lecturer, Meyerstein Institute of Clinical Oncology, MiddlesexHospital, MortimerStreet, LondonWIN 8AA, UK.

Two recent publications have reported retrospective data on symptom relief after palliative radiotherapy. A study from Sweden [5] reviewed the results of treatment of 162 patients with a short fractionation schedule giving 21 Gy in three fractions over a week. Seventy-three patients had incurable disease and the remainder were felt to be unfit for full dose irradiation. Improvement or resolution of tumour related symptoms was documented in seventy-five patients (46%) although follow-up data was missing for a proportion of the remainder. Sixty-eight patients (42%) suffered acute side effects, mainly of a minor nature. Late complications were seen in only five patients, two of whom required a colostomy and one a urinary diversion. One of these patients had received a second course of radiotherapy 8 months after the first. The second study [6] reports a survey by postal questionnaire of patients treated with palliative intent with a schedule of 30 Gy in ten fractions; no improvement in pre-treatment symptoms, other than relief of haematuria, was reported by the patients at 3 months. How then should we palliate advanced bladder cancer? Is there a 'gold standard' that we should try to achieve? In an effort to answer these questions, we recently conducted a survey of the current management of these patients with radiotherapy in the United Kingdom. A questionnaire was sent to all radiotherapy consultants known by the Royal College of Radiologists to be currently practising in the UK and Northern Ireland. They were asked to give their current regimen for local palliation and an approximation of how many such patients they would expect to treat per year. They were also asked if they would be interested in taking part in a study comparing the current standard schedule with a shorter one. One hundred and sixteen consultants (45%) returned their questionnaires, of whom 83 would be willing to participate in a study. These consultants estimated they would see, in total, per year, approximately 1000 patients suitable for palliative radiotherapy. No fewer than nine different fractionation schedules were in use, ranging from a single fraction to 4 weeks of daily treatment, with the 'modal' regimen being approximately 30 Gy over a period of 2 weeks. Interest was expressed in assessing the efficacy of a shorter schedule compared with this traditional 'standard'. On this basis we have recently undertaken a small prospective pilot study to assess the schedule used by

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Wijkstr6m et al. [5] of 21 Gy in three fractions over 5 days. We have so far recruited 13 patients over approximately 4 months. Eleven of the patients were over 70 years of age. In all patients haematuria was a presenting feature, and the majority had urinary frequency and dysuria. Three patients had urinary retention prior to starting radiotherapy, and one patient developed retention between the second and third treatments. Five elderly patients had suffered multiple recurrences of non-invasive disease and were offered radiotherapy in an attempt to reduce the frequency of repeated general anaesthetics. Patients were assessed 1 month after completing treatment to determine residual urinary symptoms, and acute bladder and bowel toxicity. Ten patients have so far been assessed at 1 month. Of the seven patients presenting with urinary frequency, symptoms had improved in five, remained static in one, and deteriorated in one. Nocturia improved in six, was constant in two and deteriorated in one. Dysuria improved in three and deteriorated in one. Haematuria was abolished in all thirteen patients. Acute bowel toxicity was seen in three patients, all at 2 weeks after completion of radiotherapy. In one patient this was a grade 3 reaction, but in all patients symptoms had resolved by 4 weeks. So far we have data on four patients at 3 months, none of whom had significant bowel or bladder symptoms. This appears, therefore, to be an effective and well tolerated schedule, at least in the short term. In the light of the interest expressed nationally, the Medical Research Council is now proposing a prospective randomized study of palliative radiotherapy for the first time in this group of patients, similar in intent to the successful studies for the palliation of

A. Lydon and G . M . Duchesne

lung cancer. In the absence of a clear consensus of what should be regarded as standard treatment, a 'control' arm of 35 Gy in ten fractions has been chosen and will be compared with the short schedule of 21 Gy described above. Eligibility will be as wide as possible to include anyone unsuitable for radical treatment or unfit for chemotherapy. Follow-up will be simple, with the primary endpoint being the grade of bladder symptoms at 3 months, although toxicity and duration of relief will also be recorded. It is hoped that the trial will be launched towards the end of 1992 and that it will help to define the gold standard for palliating this group of patients. We would encourage every clinician with an interest in these patients to consider entering them into this study.

References 1. Office of Population Censuses and Surveys. Cancer statistics: Registrations, England and Wales 1986. London: HMSO, 1991. 2. Goffiner DR, Schneider N J, Glatstein EJ, et al. Bladder cancer: results of radiation therapy in 384 patients. Radiology 1985;117:149-53. 3. Nltti VW, Macchia RJ. Bladder cancer in geriatric patients. Alternatives to radical cystectomy. Clin Geriatr Med 1990;6:173-84. 4. Fitzpatrick JM, Durazi M, Butler MR, et al. Bladder cancer in 156 patients aged 80 years or more. Ir J Med Sci 1987,156: 259-61 5. Wijkstr6m H, Nashund I, Ekman P, et al. Short-term radiotherapy as palliative treatment in patmnts with transitional cell bladder cancer. Br J Urol 1991;67:74-8. 6. Fossa SD, Hosbach G. Short-term moderate-dose pelvic radiotherapy of advanced bladder carcinoma. A questionnairebased evaluation of its symptomatic effect. Acta Oncol 1991 ;30:735-8.

Book Review Atlas of Skin Cancer. Edited by A. Du Vivier. Gower, London,

New York, 1991. Pages: 256; Illustrations: 440; Price $95.00; Hard cover. This book is notable for its quite excellent illustrations. These are alongside brief descriptions of the individual lesions, histology and clinical management. The captions with each figure are clear and histological descriptions short, to the point and make sense, even to a non dermato-histopathologist. There is a good section on normal skin histology and common benign conditions are nicely documented. Significantly, this book stresses the importance of a combined modality approach to the management of skin malignancy. Bearing in mind the biased interests of an oncologlst, the faults in this book lie in the balance of the subject matter. There is a large section on naevi and benign tumours and yet certain major skin

mahgnancies are not mentioned. The skin lymphomas, especially mycosis fungoides, S6zary syndrome, Kaposi's sarcoma and Merkel cell tumours are not represented, although there is a page devoted to a description of the Merkel cell. The sections on treatment are not complete enough to be taken as anything more than headings for further reading It is perhaps incomplete as an atlas of skin malignancy but the quahty of what is included in this book makes it a valuable addition to any library. It is also an easily digestible stimulus for examination revision, both for students and post-graduates. A. CRELLIN

Consultant Clinical Oncologist Cookridge Hospital Leeds LS16 6QB

How should we palliate bladder cancer?

Clinical Oncology(1992) 4:273-274 © 1992The RoyalCollegeof Radiologists Clinical Oncology e 2 I, OCT 92 Editorial ;~ , How Should We Palliate B...
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