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The Royal College of Radiologists recommends the use of a radiosensitiser for patients undergoing radical radiotherapy for muscle invasive bladder cancer (MIBC). Radiosensitisation with mitomycin/5-fluorouracil (BC2001) improves locoregional control of MIBC and a trial using concurrent carbogen and nicotinamide (BCON) demonstrated an improvement in overall survival. An alternative chemoradiation protocol involves weekly gemcitabine and has been shown to be efficacious and tolerable in phase 2 studies.

On a previous audit of chemoradiotherapy at the Northern Centre for Cancer Care (NCCC), disappointing rates of radiosensitisation were identified (41%, all patients received mitomycin/5FU).  On this basis, weekly gemcitabine (100 mg/m2) was introduced as an option, primarily in less fit patients. We have then reviewed chemoradiotherapy practices.

Retrospective data was collected from patients who underwent radical radiotherapy for MIBC between July 2019 and September 2021 at a large tertiary cancer centre in North-East England (NCCC, Newcastle-upon-Tyne). Those with nodal disease and/or neuroendocrine differentiation were excluded from the analysis.

Ninety-two patients were identified. Forty-eight (52%) received a concurrent radiosensitiser in the form of mitomycin/5FU (14/48, 29%) or gemcitabine (34/48, 71%). The majority receiving chemoradiotherapy were male (39/48, 81%), had a histological diagnosis of transitional cell carcinoma (41/48, 85%) and were performance status 0/1 (45/48, 94%). Median age 70.5years (range 41-80). Twenty-six percent (9/34) prescribed weekly gemcitabine failed to receive the full course due to side effects.  The most common reasons were ALT derangement (2) and bowel toxicity (4). Twenty-nine percent (4/14) of patients receiving mitomycin/5FU failed to receive the complete course of chemotherapy due to side effects. Five (10%; gemcitabine n=4, mitomycin/5FU n=1) patients experienced grade 3 bowel toxicity. Post-treatment cystoscopy reports were available in 34/48 of CRT patients and there was no evidence of local recurrence in 91% (31/34). There was no significant difference in 2-year survival rates between patients receiving gemcitabine or mitomycin/5FU (p=0.23, 95% CI 0.7 – 9.5).

Since adopting weekly gemcitabine as an alternative radio-sensitiser to mitomycin/5FU, our centre has witnessed an increase in the rate of CRT for the non-surgical management of MIBC. This is despite the period of data collection covering the COVID-19 pandemic.  Weekly gemcitabine is the more prevalent radiosensitising agent used in the treatment of MIBC within our centre.  Our experiences suggest that weekly gemcitabine is relatively easy to deliver, and it appears to be tolerable and efficacious when compared to mitomycin/5FU. The discontinuation rate of concurrent gemcitabine described above (9/34, 26%) is greater than that described in a phase 2 trial of weekly gemcitabine plus radical radiotherapy, however grade 3 toxicity rates are comparable.