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The management of elderly metastatic Renal Cell Carcinoma patients

Background

Bladder cancer is the 11st most frequent cancer in the world, with a peak incidence around 65 years of age. The most frequent presentation is non muscle invasive bladder cancer (NMIBC), accounting for 75% of all diagnosed bladder cancer.

The treatment of NMIBC is based on transurethral resection followed if needed by intravesical instillations of chemotherapy (such as MMC) or BCG. NMIBC represent an heterogeneous group of patients, some at risk of relapse, others at risk of progression to muscle invasive lesion (MIBC). Instillations are adapted to the risk factors defined by the lesion size, number of lesions, the T aned grade. BCG is a key product for the high risk NMIBC. Instillations might be associated with significant side effects, some possibly life threatening. Senior adult deserve an in depth discussion regarding the use of instillations, specially for BCG, as local situations (such as voiding dysfunction or comorbidity might expose patients to significant side effect with limited if any benefits. Better tools to optimize the risk group classification and therefore the treatment are needed, especially in senior adults.

MIBC carry an overall poor prognostic, with a 5 years survival around 60 to 70% in organ confined diseases, 40% in non organ confined and 30% for node positive patients. They are clearly undertreated in senior adults. If left untreated the local evolution is devastating, leading to untractable pain, major bleeding, and death in very poor clinical conditions. The standard of care is a major surgical procedure: the radical cystectomy with extended nodal dissection. There is no real age limit, but the significant associated 90% days postoperative mortality might explain its underuse. On top of this, post operative morbidity is significant, mainly represented by pulmonary or cardiovascular problems. Furthermore removing the bladder requires an urinary diversion which might be another reason of undertreament. Alternative exist, based on combined radiotherapy and chemotherapy, or local surgery only. The respective efficacy of each treatment must be balanced by its feasibility and agressivity and patient’s acceptance. In case of metastases, the key drug is a polychemotherapy combined with Cisplatin. The associated comorbidities, especially kidney and heart function are often real contra-indication, leading to the use of less effective regimen.

The treatment of senior adults is based on integrated teams composed of urologists, medical oncologists, radiotherapists, anesthesiologists, physiotherapists, geriatricians and dedicated nurses, all having to interact as a team. Guidelines regarding bladder cancer exist, but none are specially devoted to the senior adult population harboring a bladder cancer.

Aims

The objective of the working group is to summarize current data on prevention, early detection and its subsequent management of Bladder in the elderly, we will give an update on the available data on efficacy and safety of the several recently approved, new drugs to treat metastatic Bladder in older patients in order to establish evidence-based guidelines for older Bladder patients.

Task force experts

Chairs
Nicolas Mottet (FR) & Maria Ribal (SP)

Writing Committee
Matt Nielsen (USA)
Helen Boyle (FR)
Georgios Gakis (Germany)
Maria de Santis (UK)
Shahrokh F. Shariat (Austria)
Nicholas James (UK)
Philippe Caillet (FR)
Kilian Gust (Austria)
Young SIOG: Tullika Garg (USA)

This project is supported by an unrestricted grant from Pierre Fabre Médicament.