What is the role of neoadjuvant chemotherapy in patients undergoing radical cystectomy?

Updated: Nov 27, 2016
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Recent data support a survival benefit (6.5%) for neoadjuvant chemotherapy in patients undergoing radical cystectomy for muscle-invasive bladder cancer. The rationale is to systemically treat patients with micrometastatic disease prior to surgical removal of the bladder and lymph nodes. Up to 38% of patients who underwent neoadjuvant chemotherapy were found to have no evidence of disease at the time of cystectomy (pT0) compared with only 15% who proceeded directly to surgery. [33] However, using this treatment paradigm leads to a subset of patients who needlessly receive chemotherapy (those without systemic disease or nodal involvement). Adjuvant chemotherapy may prevent this pitfall; however, up to 30% of patients who undergo cystectomy are unable to receive indicated chemotherapy because of postoperative complications. [34]

Neoadjuvant chemotherapy followed by radical cystectomy versus radical cystectomy and risk-based adjuvant chemotherapy has never been studied in a randomized fashion. However,because of improved patient tolerance, cisplatin-based neoadjuvant chemotherapy is the currently recommended standard.


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