The natural history of invasive bladder cancer and the case against definitive radiation therapy

Recent reports of the radiosensitivity of some muscle-invasive transitional cell cancers in the bladder and the reluctance in many quarters to perform radical cystectomy with its oft-seen therapeutic failure rate have prompted the suggestion that definitive radiation be administered to all patients. Monitoring for tumor persistence or recurrence would then permit salvage cystectomy with therapeutic results approximating those seen with planned preoperative radiation and cystectomy or cystectomy alone. The fallacies of this approach, however, are that in most instances tumor will persist or recur, radiation may compromise the suitability of such patients for appropriate surgery, and a delay in such surgery may permit tumor to progress or may render such patients ineligible for additional treatment. In addition, it is entirely possible that the natural history of particular tumors may have biased results in those instances in which radiation was thought to be successful in eradicating disease. The only predictably definitive therapy for transitional cell cancer when it is truly confined to the bladder is surgery. The adjunctive role of radiation in this setting is controversial. However, the "definitive" role of radiation is not, since it can be expected to fail in most patients, and may seriously limit options for additional treatment in such patients when failure is diagnosed.