Adjuvant chemotherapy for muscle invasive urothelial carcinoma of the bladder
- Jonathan E Rosenberg, MD
Jonathan E Rosenberg, MD
- Associate Attending Physician
- Associate Professor
- Section Head, Non-Prostate Genitourinary Malignancies
- Memorial Sloan-Kettering Cancer Center
- Weill-Cornell Medical College
- Joaquim Bellmunt, MD, PhD
Joaquim Bellmunt, MD, PhD
- Director, Bladder Cancer Center
- Dana-Farber Cancer Institute
- Dana-Farber/Brigham and Women's Cancer Center
- Associate Professor, Harvard Medical School
- Cora N Sternberg, MD, FACP
Cora N Sternberg, MD, FACP
- Department of Medical Oncology
- San Camillo and Forlanini Hospitals
- Rome, Italy
Bladder cancer is the most common malignancy involving the urinary system. Urothelial (transitional cell) carcinoma is the predominant histologic type, particularly in the United States and Europe, where it accounts for 90 percent of all bladder cancers. In other areas of the world, non-urothelial carcinomas are more frequent. (See "Epidemiology and risk factors of urothelial (transitional cell) carcinoma of the bladder", section on 'Epidemiology'.)
The identification of active chemotherapy regimens in patients with metastatic urothelial carcinoma resulted in the use of both neoadjuvant and adjuvant chemotherapy. Neoadjuvant chemotherapy is associated with a survival advantage for patients with locally advanced bladder cancer, but clinicians are not yet able to identify those patients most likely to benefit from treatment , which raises the concern that some may be overtreated. As a result, many clinicians and patients opt for definitive surgery rather than neoadjuvant chemotherapy. For those patients who undergo primary surgery, adjuvant treatment may be offered, especially to patients at high risk for recurrence based on pathologic staging.
The role of adjuvant chemotherapy in patients with locally advanced urothelial carcinoma of the bladder will be reviewed here. The surgical approach to bladder cancer and the role of neoadjuvant chemotherapy are discussed separately. (See "Overview of the initial approach and management of urothelial bladder cancer" and "Radical cystectomy and bladder-sparing treatments for urothelial bladder cancer" and "Neoadjuvant treatment options for muscle-invasive urothelial bladder cancer".)
RATIONALE FOR ADJUVANT CHEMOTHERAPY
For patients with muscle invasive bladder cancer, cystectomy alone is associated with an overall cure rate that ranges from 50 to 65 percent in general, though it can be as high as 80 percent in patients who have pT2 disease . In comparison, patients with locally advanced disease are at risk for worse outcomes. The five-year survival rate in patients with invasion beyond the bladder muscle is approximately 40 percent, while the survival for patients with lymph node involvement is about 35 percent.
Given the benefit of chemotherapy in the neoadjuvant setting and the poor prognosis of patients following surgical resection, adjuvant chemotherapy is often used in patients with high-risk bladder cancer. Unfortunately, approximately 30 percent of patients experience complications following radical cystectomy that preclude them from receiving adjuvant chemotherapy .
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- RATIONALE FOR ADJUVANT CHEMOTHERAPY
- PATIENT SELECTION
- Medical fitness
- Definition of high risk
- IMPACT ON THE OUTCOMES
- EORTC Intergroup trial 30994
- Observational studies
- CHOICE OF ADJUVANT TREATMENT
- Cisplatin-based combination therapy
- Alternative chemotherapy options
- Adjuvant immunotherapy
- SUMMARY AND RECOMMENDATIONS