Urologic Oncology 4 (1998) 145–153 1078-1439/98/$–see front matter © 1999 Elsevier Science Inc. All rights reserved. PII: S1078-1439(99)00014-9 The place of radiotherapy for localized invasive bladder cancer H. Tsujii, M.D. a, *, M.K. Gospodarowicz, M.D. b , M. Bolla, M.D. c , K. Fujita, M.D. d , M’Liss Hudson, M.D. e , N. Mitsuhashi, M.D. f , J.T. Roberts, M.D. g , J. Shimazaki, M.D. h a National Institute of Radiological Sciences, Inage-ku, Anagawa 4-9-1, Chiba, 263, Japan b Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada c Department of Radiotherapy, Grenoble, France d Department of Urology, Hamamatsu University School of Medicine, Kobe, Hyogo 650, Japan e Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO, USA f Department of Radiology, Gunma University School of Medicine, Gunma, Japan g Northern Centre for Cancer Treatment, New Castle General Hospital, Newcastle, UK h Department of Urology, School of Medicine, Chiba University, Chiba-shi, Japan Manuscript accepted February 5, 1999 An ideal therapeutic regimen of primary muscle-invasive bladder cancer should achieve functional preservation with- out compromising survival rates achieved by radical sur- gery or definitive radiotherapy (RT). The evolution of blad- der preservation approaches has involved trials of definitive RT with or without limited surgery, or multimodality ap- proaches combining limited surgery, chemotherapy, and ex- ternal beam RT [1,2,3]. Radical surgery, despite improved surgical techniques with improved local control rates [4,5,6,7], may not be necessary for cure in a selected group of patients with invasive bladder cancer. Definitive RT may be as effective as radical surgery in local control and sur- vival rates, and is superior to surgery as a bladder-preserv- ing modality. The term “definitive radiotherapy” is defined as a high dose radiotherapy with an intent of curing cancer by eradicating the tumor situated in the irradiated volume [3]. Currently, the attitude of urologists toward RT in inva- sive bladder cancer may differ considerably in each country or institution. Definitive RT is the principal mode of treat- ment in the United Kingdom, whereas in many other Euro- pean countries, the United States, or Japan, the patients with resectable tumors are rarely treated with high-dose RT alone but with radical cystectomy or combined-modality therapies. This was the situation at least at the last consen- sus meeting in 1993 [3]. Recent data based on the long-term follow-up of patients show that a significant number of pa- tients can be cured by RT and retain a functional bladder [3,8,9,10], although a trend for combined-modality therapy in these regions is emerging [1,11–16]. To our knowledge, however, a randomized study comparing definitive RT ver- sus surgery alone in terms of patient survival, local control, and bladder preservation has never been done. At the previous consensus meeting, an excellent review of guidelines for definitive RT was made [3]. The useful- ness of definitive RT in the management of localized inva- sive bladder cancer was emphasized, and definitive RT was recognized as a standard bladder conservation approach, provided attention is directed to the importance of adequate patient selection and radiotherapeutic techniques. The suc- ceeding consensus conference should identify whether: (1) the ground for choosing one modality or the other has changed; (2) the patients more recently treated have had the benefit of improved surgical or radiotherapeutic techniques; (3) improved imaging techniques have contributed to more accurate staging; (4) the treatment decision made on the ba- sis of many early studies is now no longer valid; (5) the role of adjuvant or neoadjuvant chemotherapy in combined mo- dality therapy has been established; (6) updated results of radiotherapy for locally invasive bladder cancer regarding pelvic tumor control and prolonging survival in comparison with radical surgery and combined-modality therapy have been improved. 1. The impact of bladder-preservation on quality of life In the interest of quality of life (QOL) the choice of treat- ment for patients with invasive bladder cancer should achieve both adequate urinary storage and emptying of the native bladder and preserve sexual function without sacri- ficing long-term survival. However, patients with muscle- invasive cancer have traditionally undergone cystectomy with- out addressing postoperative QOL issues. In most cases, this * Corresponding author. Fax: (+81) 43-256-6507; E-mail: tsujii@nirs. go.jp.