Current Value of Neoadjuvant Chemotherapy Prior to Cystectomy

Context: Radical cystectomy with a pelvic lymph node dissection is considered the most effective treatment option today for patients with muscle-invasive bladder cancer. Unfortunately, in spite of some progress, disease-specific survival rates after cystectomy have not dramatically changed in the last few decades. The significant risk of distant failure indicates that additional systemic treatment is mandatory. Objective: The primary objective of the review was to summarize the data about the benefit of neoadjuvant systemic chemotherapy before cystectomy for muscle-invasive bladder cancer. Evidence acquisition: The papers evaluating cystectomy cohorts were analyzed including a thorough analysis of treatment failures. The papers presenting prospective randomized trials and meta-analyses on neoadjuvant chemotherapy in bladder cancer were critically reviewed. Evidence synthesis: The rationale for chemotherapy before cystectomy is to treat micrometastases beyond the margins of local therapy already present at the time of diagnosis of invasive bladder cancer. Results of prospective randomized trials indicate survival benefit after neoadjuvant platinum-based combination chemotherapy. To improve the interpretation of data from prospective randomized trials, several meta-analyses were conducted. The most recent meta-analysis, published in 2005, evaluated the individual data from 3005 patients enrolled in 11 prospective controlled trials that compared neoadjuvant chemotherapy plus local treatment with local treatment alone. The data comprised 98% of all patients from known eligible randomized controlled trials. The analysis found significant survival benefit associated with platinum-based combination chemotherapy. It was equivalent to a 5% absolute improvement in overall survival (p = 0.003) and a 9% improvement in disease-free survival (p < 0.0001) at 5 yr. Conclusions: Radical cystectomy with pelvic lymph node dissection remains the standard treatment for muscle-invasive bladder cancer. The quality of surgery is essential for optimal treatment results. The data from prospective randomized trials and meta-analyses provide support for preoperative application of platinum-based combination chemotherapy in all patients. (C) 2010 European Association of Urology. Published by Elsevier B. V. All rights reserved.