According to results recently published in The New England Journal of Medicine, neoadjuvant chemotherapy appears to improve survival in patients undergoing a cystectomy for bladder cancer.

The bladder is a hollow organ in the lower abdomen. Its primary function is to store urine, the waste that is produced when the kidneys filter the blood. Transitional cell carcinoma refers to bladder cancer involving the cells that line the inside of the bladder. Treatment of locally advanced bladder cancer (cancer that has invaded the bladder wall into the muscle, but cannot be detected elsewhere in the body) usually consists of the surgical removal of the bladder (cystectomy) and/or chemotherapy following surgery. However, approximately 50% to 60% of these patients ultimately experience a cancer recurrence, most of which are in the form of distant metastases (cancer spread from its site of origin to distant sites in the body). Thus, researchers are evaluating novel therapeutic approaches in order to reduce recurrences and ultimately improve survival for patients with locally advanced bladder cancer.

Researchers have increasingly been evaluating neoadjuvant therapy in various cancers. The rationale behind neoadjuvant therapy for bladder cancer is two-fold. First, pre-operative treatment can shrink some bladder cancers, and therefore may allow more complete surgical removal of the cancer. Second, since chemotherapy kills undetectable cancer cells in the body, it may help prevent the spread of cancer when used initially rather than waiting for patient recovery following the surgical procedure. Thus far, results from clinical trials have demonstrated conflicting results with the use of neoadjuvant chemotherapy for the treatment of bladder cancer.

Researchers affiliated with the Southwest Oncology Group recently conducted a clinical trial to further evaluate neoadjuvant chemotherapy in patients with locally advanced bladder cancer. This trial involved over 300 patients who were treated either with neoadjuvant chemotherapy consisting of methotrexate, vinblastine, doxorubicin and Platinol® (MVAC) followed by a cystectomy or a cystectomy alone, and outcomes from the two groups were directly compared. The average duration of survival for patients less than 65 years of age was 104 months for those treated with neoadjuvant therapy, compared with 67 months for those treated with cystectomy only. For patients 65 years or older, the average survival was 61 months for those treated with neoadjuvant therapy, compared to only 30 months for those treated with cystectomy only. At approximately 5 years following therapy, 57% of patients treated with neoadjuvant therapy were alive, compared with only 43% of patients treated with cystectomy only. Treatment with neoadjuvant therapy caused moderate side effects, particularly low white blood cell levels. However, there were no treatment-related deaths and no complications from surgery due to treatment with chemotherapy.

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The researchers concluded that neoadjuvant chemotherapy with MVAC improves survival in patients with locally advanced bladder cancer who are to undergo a cystectomy. Patients with locally advanced bladder cancer should discuss the risks and benefits of neoadjuvant chemotherapy with MVAC, Gemzar®/Platinol® or other chemotherapy regimens with their physician.

Reference: Grossman H, Natale R, Tangen C, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer.

The New England Journal of Medicine. 2003;349:859-866.