Which patients benefit the most from neoadjuvant chemotherapy in advanced bladder cancer?

Despite 5% advantage in 5-year overall survival, neoadjuvant chemotherapy may result in considerable overtreatment of bladder cancer patients because of the lack of response criteria. The review's purpose was to identify the criteria on which the selection of bladder cancer patients for neoadjuvant chemotherapy followed by radical cystectomy should be based.

About 30-40% of patients with metastatic bladder cancer are ineligible for platinum-based neoadjuvant chemotherapy because of renal impairment. Stratification based on the clinical tumor stage is likely to be biased by inappropriate preoperative staging. Differences in the response to neoadjuvant chemotherapy seem not to be predictable by histological subtype of bladder cancer. Future developments in radiological imaging, molecular cancer staging and response prediction aim to identify patients who will profit from neoadjuvant chemotherapy.

Patients considered for neoadjuvant chemotherapy should be eligible for cisplatinum-based regimens. To avoid overtreatment, preferably patients with nonorgan-confined and lymph-node disease should be treated by neoadjuvant chemotherapy. However, the possibility of staging error should be taken into account. Patients with limited metastatic disease may also profit from neoadjuvant chemotherapy followed by radical cystectomy with concomitant metastasectomy.