Systemic chemotherapy is the only modality that has been shown in phase 3 trials to improve survival in responding patients with advanced bladder cancer).The M-VAC regimen, first reported in 1985 by investigators from Memorial Sloan-Kettering Cancer Center, revealed that urothelial carcinoma was sensitive to chemotherapy. Patients with measurable lesions were found to have a remarkably high response rate of 72%, and 36% attained complete response. Long-term survival was achieved in patients who attained complete response. In addition, patients who achieved a complete response with the combination of chemotherapy and surgery had twice the survival of patients who had only a partial response to chemotherapy and no further surgery (level 3). The median overall survival time for the whole group was 13.1 months. Chemotherapy was more effective in patients with nodal disease only compared with patients who had visceral metastases.
In an update of these results, a retrospective analysis of 5 different M-VAC trials encompassing 203 patients from Memorial Sloan-Kettering Cancer Center was reported. Among 194 evaluable patients, 46 patients achieved a complete response (24%) and 84 patients a partial response (43%), yielding an overall response rate of 67%. The median survival time for all 203 patients was 14.8 months, with a 5-year survival rate of 17% (level 3). The 5-year survival rate for the 46 patients with a complete response after chemotherapy alone was 40%. An additional 30 patients achieved complete response after chemotherapy followed by surgery, with a 5-year survival rate of 33%.Similar results apply in the treatment of metastatic disease.
In the Memorial Sloan-Kettering Cancer Center experience, M-VAC has been associated with severe toxicity and long-term survival in only 15% of patients with visceral metastases and in 30% of patients with nodal disease. The need for improved efficacy and reduced toxicity has led investigators to continue to seek less toxic and more effective regimens. A number of such regimens have been tried. Although CM, CMV, and M-VAC have never been compared in randomized studies, most centers have considered M-VAC to be the standard regimen.
Von der Maase H, Hansen SW, Roberts JT, et al. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol 2000;18:3068-3077
NCCN.ORG, Bladder cancer
C. Sternberg, S. Donat, J. Bellmunt, R. Millikan, W. Stadler, P. De Mulder, A. Sherif, H. von der Maase, T. Tsukamoto, M. Soloway, Chemotherapy for Bladder Cancer: Treatment Guidelines for Neoadjuvant Chemotherapy, Bladder Preservation, Adjuvant Chemotherapy, and Metastatic Cancer.
Urology, Volume 69, Issue 1, Pages 62-79, 2007