A Systematic Review of Neoadjuvant and Adjuvant Chemotherapy for Muscle-invasive Bladder Cancer
Cet article passe en revue les travaux récents sur l'intérêt d'une chimiothérapie néoadjuvante ou adjuvante dans le cancer invasif de la vessie
Context: Muscle-invasive bladder cancer (MIBC) is a disease with a pattern of predominantly distant and early recurrences. Neoadjuvant cisplatin-based combination chemotherapy has demonstrated improved outcomes for MIBC. Objective: To review the data supporting perioperative chemotherapy and emerging regimens for MIBC. Evidence acquisition: Medline databases were searched for original articles published before April 1, 2012, with the search terms bladder cancer, urothelial cancer, radical cystectomy, neoadjuvant chemotherapy, and adjuvant chemotherapy. Proceedings from the last 5 yr of major conferences were also searched. Novel and promising drugs that have reached clinical trial evaluation were included. Evidence synthesis: The major findings are addressed in an evidence-based fashion. Prospective trials and important preclinical data were analyzed. Conclusions: Cisplatin-based neoadjuvant combination chemotherapy is an established standard, improving overall survival in MIBC. Pathologic complete response appears to be an intermediate surrogate for survival, but this finding requires further validation. Definitive data to support adjuvant chemotherapy do not exist, and there are no data to support perioperative therapy in cisplatin-ineligible patients. Utilization of neoadjuvant cisplatin is low, attributable in part to patient/physician choice and the advanced age of patients, who often have multiple comorbidities including renal and/or cardiac dysfunction. Trials are using the neoadjuvant paradigm to detect incremental pathologic response to chemobiologic regimens and brief neoadjuvant single-agent therapy to screen for the biologic activity of agents. Take Home Message: Data support cisplatin-based combination chemotherapy preceding cystectomy for muscle-invasive bladder cancer. Despite lack of definitive evidence, high-risk patients qualifying for cisplatin may be offered adjuvant chemotherapy. The neoadjuvant paradigm may expedite the development of more active regimens.
European Urology 2012