What is the role of cisplatin-based neoadjuvant chemotherapy in the treatment of bladder cancer?

Updated: Feb 23, 2021
  • Author: Kara N Babaian, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Cisplatin-based neoadjuvant chemotherapy has become the standard of care in muscle-invasive bladder cancer. [70] Giving chemotherapy prior to radical cystectomy may improve cancer-specific survival, presumably by treating micrometastatic disease and pathologic downstaging. [120] A meta-analysis of 11 trials showed an overall survival rate benefit of 5% in patients who received neoadjuvant chemotherapy. [121]

If locally advanced TCC is suspected, based on clinical staging, the rationale for neoadjuvant chemotherapy prior to cystectomy may be even stronger. In a SWOG multicenter, randomized, prospective study of neoadjuvant therapy with a combination of methotrexate, vinblastine, doxorubicin, and cisplatin, the investigators concluded that neoadjuvant therapy conferred a treatment benefit compared with surgery alone for locally advanced bladder cancer. [122]  Median survival in patients treated with surgery was 46 months as compared to 77 months in patients assigned to receive neoadjuvant MVAC followed by cystectomy.  [122]

However, several criticisms of this study exist. The study was underpowered because of slow recruitment (317 patients over 11 y), because 20% of the patients who were to undergo cystectomy alone never had the surgery, and because there was no comparison to neoadjuvant therapy alone or adjuvant therapy. In addition, a study that reevaluated the SWOG data found that surgical factors significantly affected outcomes. [123]

The gemcitabine and cisplatin combination is frequently substituted for the classic MVAC. Studies have shown non-inferiority to the MVAC regimen. The American Urological Association (AUA) states that cisplatin plus gemcitabine is widely accepted by the oncology community as an alternative to MVAC because of its better tolerability. [124]   

A phase III trial that assessed 976 patients with muscle-invasive bladder cancer using neoadjuvant cisplatin, methotrexate, and vinblastine (CMV) chemotherapy found that risk of death was decreased by 16%. Chemotherapy was followed by cystectomy and/or radiotherapy. [125]

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