How to treat muscle-invasive bladder cancer in elderly?

Question

Hi doctor,

My father was diagnosed with muscle-invasive bladder cancer seven months back, and some enlarged local nodes, and then three months back, it moved to his sacrum bone. He received four cycles of Gem (gemcitabine)/Cis (cisplatin) over the course of three months.

Last month, he was scheduled for surgery, but came down with COVID-19, so it was postponed to today. Yesterday, his PET (positron emission tomography) scan revealed many new findings. We are still removing the bladder because of his severe symptoms, and then we will be starting immunotherapy and radiation treatments in a couple of weeks. What do you think? And how long can one expect to live with these results?

Impression:

1. Redemonstrated asymmetric thickening of the bladder dome and left lateral wall, consistent with the primary site of disease.

2. New multiple FDG-avid lung nodules, most likely representing metastasis.

3. Increased retroperitoneal and bilateral pelvic metastatic lymphadenopathy.

4. Increased extent of the sacral osseous lesion with pathologic fracture, representing metastatic disease.

5. The additional FDG uptake (radiotracer uptake) in the L1 spinous process may represent osseous metastasis. However, posttraumatic change can demonstrate a similar finding.

6. Small but FDG-avid left mediastinal lymph nodes are indeterminate and may represent metastasis.

7. Focal increased FDG uptake in the right side of the root of the penis without a definite CT correlate may represent metastatic disease.

Please help.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

I have reviewed the information (attachment removed to protect patient identity) provided.

In my very limited opinion (as I have not seen the patient myself, and there can be other information that has been omitted in this query), surgery in the form of complete bladder removal is usually not required in metastatic bladder cancer.

Even for symptom relief, minimal surgery and radiation are usually preferable.

Regarding survival, we need to consider the performance status of the patient, to begin with. Moreover, the response to chemotherapy is also very important. In your case, the disease is progressive on first-line chemo. This makes disease control a very difficult goal to achieve.

Immunotherapy and radiation cannot eradicate the disease completely.

So overall, I am afraid it is not a promising situation. To the best of my knowledge, the five-year survival is around 5 %, and immunotherapy might boost that up by a small percentage.

Participation in a running clinical trial might be the best treatment option for him.

Still, this is a very limited opinion; do verify it with your doctor.

I hope this information will help you.

Kindly follow up if you have more concerns.

Thank you.