A Review of Neoadjuvant and Adjuvant Chemotherapy for Nonmetastatic Muscle Invasive Bladder Cancer

Radical cystectomy is the standard treatment for muscle invasive bladder cancer but survival remains poor with radical cystectomy alone. We reviewed the relevant available data on adjuvant and neoadjuvant chemotherapy for bladder cancer.

We performed a MEDLINE® database literature search to identify original articles and meta-analyses. A key word search was done using the terms urinary bladder neoplasms, cystectomy, chemotherapy, and adjuvant and neoadjuvant therapy. The search was restricted to adults.

We studied adjuvant chemotherapy in several prospective, randomized trials that demonstrated improvement in disease-free survival. Many of the trials failed to achieve the target number of accruals, closed early or had major flaws in design. Evidence of the use of neoadjuvant chemotherapy was based on more robust studies that showed a small but significant 5% improvement in overall survival. However this benefit concerned a small set of patients who responded to chemotherapy while another set seemed to fare well with or without neoadjuvant chemotherapy.

Perioperative chemotherapy improves survival in patients with muscle invasive bladder cancer. Molecular predictors of the response to chemotherapy are still in the investigational phase and not yet incorporated into clinical practice. Thus, a risk adapted approach by reserving neoadjuvant chemotherapy for cisplatin eligible patients with high risk disease features may balance the benefits of neoadjuvant chemotherapy while minimizing overtreatment.