The Treatment of Advanced Carcinoma of the Bladder

The treatment of advanced carcinoma of the bladder has proved unsatisfactory, whatever the method, whether radiotherapy or surgery. The advent of “supervoltage therapy” was therefore greeted with great hopes and expectations as a possible means of improving results where other procedures were known to have failed. Various preliminary reports have appeared in the course of recent years on this subject, some describing favorable results, others less optimistic, but no large groups have been followed for five years or longer. It is hoped that this additional report on a total of 89 patients who were treated at the Francis Delafield Hospital, New York, between January 1951 and January 1960 may add some information which will be helpful in the difficult problem presented by recurrent or primary advanced carcinoma of the bladder. Two groups of patients will be evaluated: one, a group of 79 who received either two-million volt or cobalt-60 therapy, and a second, smaller group of 10, who were treated with a combination of radiation, either two-million-volt or cobalt-60 irradiation, and a surgical procedure. The group of 79 patients who were given either two-million-volt or cobalt-60 therapy will be considered first. Forty-two of these had already received various types of treatment when we saw them for the first time. Known distant metastases were present in 14 before the beginning of therapy. It is obviously difficult, if not impossible, to classify such a group according to the staging suggested by Whitmore and Marshall (Table I), but it can be said that none of our cases were of Stage a or Stage A. Nine were classified as questionable Stage B1, but were more likely Stage B2 when we first saw them. Fourteen were classified as Stage D2 and the remaining 66 patients had disease of either Stage B2 or Stages C or D1. Many of the tumors treated with other methods, originally not deeply invasive, had become advanced and deeply invasive at the time the patient was first seen in our hospital. Table II shows the microscopic classification of the disease in this patient group: Sixty of the patients were male and 19 female. Our youngest patient was thirty-seven and the oldest eighty-eight years of age at the beginning of therapy. The treatment approach in this group has depended on various factors; first, of course, on the extent of the disease and on the previous treatment. Advanced recurrent carcinoma and cases with known metastases were treated with limited intent only, in the hope of controlling the local disease for some time, and of keeping the patient comfortable as long as possible. The tumor dosage used in this group was 3,000 r, delivered in three weeks through large opposing pelvic fields, though there were, of course, individual variations. Nor was the dosage in the other patients completely uniform.