Integrating Perioperative Chemotherapy into the Treatment of Muscle-Invasive Bladder Cancer: Strategy Versus Reality

Since the initial report in 2003 of the Intergroup-0080 trial confirming benefit of combined neoadjuvant M-VAC (methotrexate,vinblastine, adriablastine, and cisplatin) chemotherapy and cystectomy in the treatment of muscle-invasive bladder cancer, debate has continued in the literature as to the relative risk/benefits of integrating perioperative chemotherapy into the care of patients, especially in those with organ-confined, muscle-invasive, node-negative disease in whom the benefit may be less. Because of the inaccuracies of clinical staging, the potential morbidity related to M-VAC chemotherapy, a 70% cure rate in pT2No disease with surgery alone, and only a modest (5%) improvement in absolute overall survival with combined therapy, many favor limiting chemotherapy to patients with a pathologic stage of pT3 or greater or node-positive disease. This philosophy was also reflected in the 2008 National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Bladder Cancer, in which neoadjuvant chemotherapy for clinical T2 disease versus adjuvant therapy based on pathologicrisks is only "considered." Additionally, a recent study looking at the perioperative integration of chemotherapy for stage III bladder cancer in the United States using the National Cancer Data Base showed that only 11.6% of patients underwent any perioperative chemotherapy, with Most in the adjuvant setting. These findings indicate that despite randomized trial data showing survival benefit for perioperative chemotherapy, and the current guidelines for therapy supporting those findings, chemotherapy is not being integrated well into the care of patients with muscle-invasive bladder cancer, even in those who, experts agree, have the most potential for benefit. (JNCCN 2009;7:40-47)