Review of Current Neoadjuvant and Adjuvant Chemotherapy in Muscle-Invasive Bladder Cancer

Context: There are > 8000 cases of bladder cancer per year in France, and 30% are muscle invasive. Despite an aggressive initial treatment, only 60% of patients with T2 tumours, 50% with T3a, and 15% with T3b stage tumours will be alive at 5 yr. Objective: To address the role of chemotherapy in urothelial tumours of the bladder. Evidence acquisition: Published randomised trials of chemotherapy in urothelial tumours of the bladder in both neoadjuvant and adjuvant settings from 1980 and 2010 and corresponding meta-analyses were included in this review. Evidence synthesis: In the neoadjuvant setting, a meta-analysis of individual data from 3005 patients included in 11 randomised neoadjuvant chemotherapy trials for localised muscle-invasive bladder cancers demonstrated an absolute survival benefit of 5% at 5 yr with cisplatin-based combination chemotherapy. Despite these results, neoadjuvant chemotherapy is very rarely proposed for this indication. Comparative trials undertaken in the adjuvant setting have been limited by major methodological weaknesses (eg, very low statistical power and unwarranted early trial interruptions) preventing definitive conclusions. In a meta-analysis based on individual data from 491 patients, a 25% reduction in death risk was observed for an absolute gain of 9% at 3 yr. However, the small number of patients included and the heterogeneity of the chemotherapy protocols used limit the validity of these analyses. Conclusions: Given this uncertainty, chemotherapy should be offered early and proposed as a reasonable option for patients for tumours with extravesical extension or with nodal involvement detected postoperatively. (C) 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.