Meta-analysis of neoadjuvant chemotherapy compared to radical cystectomy alone in improving overall survival of muscle-invasive bladder cancer patients

Abstract

Background Most patients with muscle-invasive bladder cancer (MIBC) developed metastasis within 2 years, even after radical cystectomy (RC). The recurrence rate of MIBC was more than 50% of the cases. A meta-analysis conducted by Yin et al. showed that neoadjuvant chemotherapy (NAC) + RC improves overall survival in MIBC compared with RC only. However, a new meta-analysis by Li et al. concluded that NAC + RC was not superior to RC only in improving overall survival. The inconsistencies of these studies required further comprehensive analysis to recommend NAC use in bladder cancer treatment. Therefore, this meta-analysis aims to analyze previous studies that compare the efficacy of NAC + RC versus RC only to improve overall survival of MIBC. Methods The articles were searched using Pubmed with keywords “muscle-invasive bladder cancer”, “neoadjuvant chemotherapy”, “cystectomy”, and “overall survival”. The articles that were published until June 2020 were screened. The overall survival outcome was analyzed as hazard ratio (HR) and presented in a forest plot. Result Seventeen studies were included in meta-analysis with a total sample of 13,391 patients, consist of 2890 received NAC followed by RC and 10,418 underwent RC only. Two studies used methotrexate/vinblastine/doxorubicin/cisplatin (MVAC), two studies used gemcitabine/cisplatin (GC), one study used Cisplatin-based regimen, one study used MVAC or GC, one study used gemcitabine/carboplatin (GCarbo) or GC or MVAC, one study used Cisplatin/Gemcitabine or MVAC, one study used Cisplatin only, one study used Cisplatin-based (GC, MVAC) or non-Cisplatin-based (combined paclitaxel/gemcitabine/carboplatin), one study used GC, MVAC, Carboplatin, or Gemcitabine/Nedaplatin (GN), and five studies did not mention the regimen The overall survival in the NAC + RC only group was significantly better than the RC only group (HR 0.82 [0.71–0.95], p = 0.009). Conclusion NAC + RC is recommended to improve overall survival in MIBC patients. A further study assessing side effects and quality of life regarding NAC + RC is needed to establish a strong recommendation regarding this therapy.

Outcomes for Muscle-invasive Bladder Cancer with Radical Cystectomy or Trimodal Therapy in US Veterans

“…Outcomes may differ at centers based on volume. Notably, among patients with RC, addition of NAC was not associated with decreased mortality on multivariable analysis, contrary to a recent meta-analysis showing an 18% reduced risk of OM (HR 0.82, 95% CI 0.71–0.95; p < 0.01) [21] . The differing results may reflect the lower case volumes observed per site in the VA, as many previous studies are from high-volume academic centers.…”

Recurrence of Aggressive Urothelial Carcinoma in an Ileal Neobladder without Involvement of Remaining Urothelium

“…Recurrence of urothelial carcinoma after radical cystectomy is not uncommon. [1][2][3][4][5][6] Recurrence rates have been seen to be lower if a patient is treated with neoadjuvant micrometastatic-targeting chemotherapy. 6,7 Recurrence rates increase with higher stages of disease on cystectomy and with nodal involvement.…”

A practical approach to bladder preservation with hypofractionated radiotherapy for localised muscle-invasive bladder cancer

“…Platinum-based combination chemotherapy provides an absolute overall survival benefit of 5% and disease-free survival benefit of 9% at 5 years 5,15 . It treats micro-metastatic disease and allows for potential of downsizing tumour volume, especially for patients with large tumours where TURBT is difficult or completeness is not possible.…”