Neoadjuvant and adjuvant chemotherapy in locally advanced bladder cancer

Patients with muscle-invasive bladder cancer are at a high risk for systemic relapse after cystectomy or radiotherapy. Predictors of relapse include stage, size of the primary tumor, histological grade, vascular invasion, and presence or absence of nodal metastases. The data currently available from both nonrandomized and randomized trials have not definitively established the impact on survival of neoadjuvant or adjuvant chemotherapy. Response to neoadjuvant chemotherapy is an important predictor of survival. Patients with high-stage or unresectable disease are appropriate candidates for neoadjuvant chemotherapy. Bladder preservation after neoadjuvant chemotherapy is a controversial issue which will require validation in randomized trials. Adjuvant chemotherapy may prolong disease-free survival in patients at high risk for relapse after cystectomy (pT3b, pT4, and N+).