Classification and Staging of Bladder Carcinoma.

Bladder carcinoma is a chronic, heterogeneous, field-change, neoplastic diathesis in most of the patient., that it afflicts. Staging initially considered the primary lesion(s) and local nodal involvement (Jewett-Strong-Marshall), but variable disease characteristics cannot be accommodated by this system. For clinical research purposes, longitudinal observations on patients with bladder carcinoma seem useful for identifying and classifying types of patients with types of urothelial neoplasms. For general use, however, the classification of the American Joint Committee provides for common taxonomy concerning the primary tumor(s), T(m); nodal involvement, (N); metastases, (M); grade, (G); and lymphatic involvement, (L+/L-). It also provides for indicating how the information for each of these tumor characteristics or activities was obtained, i.e. clinical, (cT); surgical biopsy of a metastatic pelvic node, (sN+); or pathological evaluation of cystectomy specimen, (pTpN). This system clearly describes patients in different stages of disease treated by different modalities, using previously defined rules. It should be employed in initial and subsequent follow-up of patients, particularly when analyzing the results of treatment.

Chemotherapy Programs of the National Prostatic Cancer Project (NPCP).

Results of the first nationally randomized trial of the National Prostatic Cancer Project revealed a demonstrable advantage for chemotherapy in the management of advanced disease (Stage D in relapse from endocrine therapy). Both cyclophosphamide and 5-Fluorouracil showed improved activity over standard therapy. A second trial for patients previously irradiated, with less tolerance to myelosuppressive agents, revealed an advantage for estramustine phosphate and streptozotocin over standard therapy. Subsequently completed trials have revealed activity for prednimustine and imidazole carboxamide (DTIC). Trials currently underway for newly-diagnosed Stage D and for Stage D disease clinically stable to diethylstilbestrol (DES) show promising activity for DES combined with cyclophosphamide. Current trials with single agents in advanced disease are comparing methyl-CCNU and hydroxyurea with cyclophosphamide; another is evaluating estramustine phosphate and vincristine alone and in combination. The use of chemotherapy in earlier staged patients as adjuvants to definitive surgery or irradiation is underway in two clinical trials, where the effect of cyclophosphamide and estramustine phosphate as long-term therapies is compared with no additional treatment.

Age and comorbidity impact surgical therapy in older bladder carcinoma patients: a population-based study.

BACKGROUND: Bladder carcinoma often occurs in older patients who also may have other comorbid conditions that could influence the administration of surgical therapy. The current study was conducted to describe the distribution of comorbid conditions in patients with bladder carcinoma and ascertain whether these conditions, as grouped by the American Society of Anesthesiologists physical status classification, affected the choice of surgical therapy. METHODS: The authors examined six population-based cancer registries from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program in 1992. A total of 820 individuals age 55 years and older was found. A random sample of newly diagnosed bladder carcinoma patients were stratified according to registry, age group (ages 55-64 yrs, ages 65-74 yrs, and age 75 yrs and older), and gender. Data regarding comorbid conditions were abstracted from the medical records and merged with routinely collected cancer registry data. The main outcome measures were the prevalence and distribution of comorbid conditions, American Society of Anesthesiologists physical status classification, and the receipt of cystectomy in patients with muscle invasion. RESULTS: Hypertension, chronic pulmonary disease, arthritis, and heart disease were found to affect at least 15% of the study population. Approximately 38% of patients were current or former smokers. Greater than 90% of patients with superficial disease were treated with transurethral resection alone. Among those patients with muscle invasion, only 55% of those ages 55-59 years underwent cystectomy; this percentage dropped to 4% in patients age 85 years and older. Among patients with an American Society of Anesthesiologists physical status classification of 0-2, the cystectomy rate ranged from 53% in those ages 55-59 years to 9% in those age 85 years and older. CONCLUSIONS: There were no significant treatment differences noted with regard to age among patients with superficial disease. Among those patients with muscle invasion, those age 75 years and older were less likely to undergo radical cystectomy (14%) compared with patients ages 55-64 years (48%) and those ages 65-74 years (43%). Patient age may contribute to treatment decisions in patients with muscle-invasive disease, even when comorbidity is taken into account.

Survival experience of black patients and white patients with bladder carcinoma.

BACKGROUND: Blacks are less likely than whites to develop bladder carcinoma. However, once they are diagnosed, black patients experience poorer survival. The authors investigated which factors were related to survival differences in black patients and white patients with bladder carcinoma stratified by extent of disease. METHODS: A population-based cohort of black patients with bladder carcinoma and a random sample of frequency-matched white patients with bladder carcinoma, stratified by age and gender, were identified through cancer registry systems in Atlanta, New Orleans, and San Francisco/Oakland. Patients had no previous cancer history and were ages 20-79 years at the time they were diagnosed with bladder carcinoma in 1985-1987. Medical records were reviewed at initial diagnosis, and 77% of patients were interviewed. Tumor grade, T classification, and other variables, including age, socioeconomic position, symptom duration, smoking history, and comorbidities, were recorded. Survival of black patients and white patients by extent of disease was modeled using Cox regression analysis. RESULTS: A greater proportion of black patients had histologic types of tumors that were associated with poorer survival. Among those with pure urothelial carcinoma, black patients had greater extent of disease at the time of diagnosis. Within specific extent-of-disease categories, there was some evidence of poorer survival for black patients with T2 tumors and strong evidence of poorer survival among those with T3 tumors compared with white patients. Black patients with muscle-invasive carcinoma who died within 6 months of diagnosis tended to present with life-threatening symptoms. Black patients and white patients did not differ with respect to diagnostic tests performed or therapy given. CONCLUSIONS: Black patients with bladder carcinoma had poorer survival due to greater extent of disease at diagnosis and a higher proportion of more aggressive histologies compared with white patients. Within urothelial carcinomas, by extent of disease (clinical/pathologic stage) these black/white survival differences were limited to patients with muscle invasion (T2 and T3 tumors).