Adjuvant Chemotherapy in Bladder Cancer: A Good Concept But Where’s the Proof?

Abstract

Cystectomy and pelvic lymphadenectomy for locally advanced (T3/T4, N+) bladder cancer is associated with high rates of disease recurrence and death. In an effort to improve the outlook for patients with this disease, postoperative chemotherapy has been investigated. Using cisplatin-based combinations which are shown to be safe and effective in the metastatic setting, this strategy permits selection and treatment of patients at highest risk for disease recurrence and death, based on findings at the time of surgery. But despite the high prevalence of bladder cancer, studies of adjuvant chemotherapy to date incorporate fewer than 500 patients altogether, and provide insufficient statistical power to show a survival benefit. Furthermore, the clinical significance of a demonstrated improvement in disease-free survival is uncertain given the ability of chemotherapy to salvage some patients at relapse. Although adjuvant chemotherapy is conceptually attractive, enrollment in ongoing clinical trials is needed to identify whether adjuvant chemotherapy cures more patients than surgery alone for locally advanced bladder cancer.