What is the best approach to management of newly diagnosed intermediate or high risk prostate cancer in a patient with high grade non-muscle invasive bladder cancer?
Perhaps the term "Best Approach" should be eyed with skepticism in the field of genitourinary radiation oncology.
Is there extensive disease in the bladder, focal recurrences, or no visualizable lesions? The maintenance BCG element of the question suggests the patient has minimal measurable disease in the bladder at this point.
The approach will depend on the life expectancy and medical comorbidities of the patient. Even a T1 bladder cancer patient already carries a 5% risk of nodal involvement, and high grade is serious business, with an almost inevitable chance of progression.
If this were a 77 year old man with 2 stents, diabetes, and 80 pack year smoking history, and he was a 3+4=7 Gleason in 2 cores with PSA of 6...I would do nothing other than expectant management of the prostate and continue maintenance BCG.
If this is a 59 year old healthy man with 4+3=7 Gleason, 50% cores positive, PSA doubling time 9 months, PSA 14...it's a whole other story. In this case, cystoprostatectomy sounds like one really good option for him, and probably the one I would advocate.
If that same patient wanted to avoid surgery, or disliked the idea of an ileostomy, then you could treat him definitively with radiation for both malignancies. In a case like that, the biggest question on the table for the man who cannot or will not have surgery is one of concurrent chemotherapy for the high grade bladder cancer. There is evidence for definitive RT for T1 high grade, and RTOG is investigating this right now with chemorad. Would you dose -de-escalate the prostate dose if you had chemo on board for the bladder and EBRT only? Perhaps a seed implant boost and definitive chemoRT is a choice. Again, I would encourage surgery for this case if possible and hold radiation as an adjuvant/salvage if necessary. I have never had a good life-expectancy, healthy patient referred to me for bladder cancer...so this case seems academic.
How about this case....similar to ones I have actually treated several times: 72-year old man, so-so on the eyeball test, life expectancy ~ 10 years. Gleason 4+3=7, T2b prostate, PSA 12, 75% core positive. no MI, early diabetes, HTN, obese, 40 pack year smoker quit smoking 10 years ago . Here is where it gets interesting... With 3 intermediate risk prostate cancer factors he has a legit probability of developing metastasis within 3 years from prostate cancer (same is true for high grade bladder). This guy I would start ADT, probably treat Pelvic nodes + Bladder + Prostate + seminal vesicles to 50.4 Gy, boost entirety of bladder and prostate and sem ves to 59.4-63 Gy depending on DVH discomforts, then boost prostate +sem ves to 79.2Gy. I would not use chemo, relying on the fact that the surgeons where I work would begrudgingly consider Cystoprostatectomy if I failed (although they would constantly remind me how hard it was and how badly I screwed them over by putting them in this position in the first place...and they would be right... and then I would remind them that they sent the patient to me in the first place because he was too high a "surgical risk" :) )
Best approach? None. Very individualized therapy taking into account the whole picture is the only answer....surgical management usually preferred.
Thats my 2 cents...
Jonathan D. Tward, M.D., Ph.D
Co-Leader, Genitourinary Malignancies Disease-Oriented Team
Associate Professor
Department of Radiation Oncology
Huntsman Cancer Institute
University of Utah
Webpage: http://goo.gl/BllR6B