Neoadjuvant chemo for bladder cancer – pro

Randomized clinical trials of neo-adjuvant cisplatin-based combination chemotherapy for locally advanced muscle invasive bladder cancer has shown a survival benefit over cystectomy alone. Pathologic complete response (pT0) after neo-adjuvant chemotherapy is emerging as a potentially important surrogate clinical end point.

The advantages of neo-adjuvant chemotherapy over an adjuvant design include: (1) better tolerance of chemotherapy prior to cystectomy than post-operatively; (2) avoidance of delay in administering chemotherapy due to post-operative morbidity and recuperation often encountered in the adjuvant approach; (3) urinary diversion after radical cystectomy may be associated with some decrement in renal function, thus limiting the use of adjuvant cisplatin, one of the most active agents in bladder cancer. Furthermore, neo-adjuvant chemotherapy allows individual assessment of in vivo tumor response, which can be a guide to future chemotherapy agent selection. Also, downstaging allows for better resectability, and in some selected patients, bladder conservation . The main disadvantage of neo-adjuvant chemotherapy is that definitive local therapy (cystectomy or radiotherapy) is delayed during the treatment period. Furthermore, significant toxicity associated with neo-adjuvant chemotherapy may preclude potentially curative definitive local therapy. In addition, given that neo-adjuvant therapy relies on clinical (rather than pathologic) staging, some low-stage, low-risk patients may unnecessarily receive chemotherapy.

Vale C and Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. (2003) Neo adjuvant chemotherapy in invasive bladder cancer: a systematic review and meta-analysis. The Lancet 361:1927–1934.

Winquist E, Kirchner TS, Segal R, et al. (2004) Neo-adjuvant chemotherapy for transitional cell carcinoma of the bladder: a systematic review and meta-analysis. J Urol 171:561–569 (2 Pt 1).

Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. (2005) Neo-adjuvant chemotherapy in invasive bladder cancer: update of a systematic review and meta-analysis of individual patient data. Eur Urol 48:202–205

R Sawhney et al, Neo-adjuvant chemotherapy for muscle-invasive bladder cancer: a look ahead Annals of Oncology 2006 17(9):1360-1369;

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