Perioperative chemotherapy for bladder cancer

The presence of occult micrometastases at the time of radical cystectomy leads to both distant and local failure in patients with locally advanced transitional cell carcinoma of the bladder. Cisplatin-based chemotherapy produces responses in 40-60% of patients with metastatic bladder cancer. Perioperative administration of chemotherapy in bladder cancer patients theoretically can impart the same survival benefits demonstrated in patients with breast, lung and colon cancer. Both neoadjuvant and adjuvant therapy have been evaluated in patients with locally advanced bladder cancer. Studies evaluating adjuvant chemotherapy have been limited by inadequate statistical power to detect meaningful clinical answers, as well as experimental arms utilizing inadequate chemotherapy. Two randomized clinical trials have demonstrated a survival benefit for neoadjvuant CMV (Cisplatin, Methotrexate, Vinblastine) or MVAC (methotrexate, vinblastine, adriamycin, cisplatin). The aggregate of available evidence suggests that neoadjuvant cisplatin-based combination chemotherapy should be considered a standard of care for patients with muscle-invasive/locally advanced operable bladder cancer. However, some physicians prefer to defer chemotherapy until after surgery, when pathologic stage is defined, as well as the risk of relapse. In patients who are either unfit for or refuse radical cystectomy, neoadjuvant chemotherapy with or without radiation can render bladder preservation possible in patients who attain pathologic major response.