Adjuvant and neoadjuvant chemotherapy for urothelial carcinoma

Transitional cell carcinoma of the bladder is associated with a high relapse rate, locally and systemically, particularly in patients with nodal or soft-tissue involvement, despite radical cystectomy. The responsiveness of the disease to chemotherapy in the metastatic setting has stimulated the use of systemic therapy in earlier stage disease, either before (neoadjuvant) or after (adjuvant) definitive local therapy. Interpretation of the data is hampered by low patient accrual to randomized trials, lack of standardization of local treatment modalities, and the use of a variety of chemotherapy agents and regimens pointing to the difficulty in reaching a consensus as to what constitutes standard therapy. In this article, we review the use of adjuvant and neoadjuvant chemotherapy, the advantages and disadvantages of both approaches, and the recommendations that can be made based on available data. New approaches to improving survival, potentially with organ preservation, include the development of more effective chemotherapy, and the identification of prognostic features-clinical or biologic-that might be a better guide to patient selection.