Perioperative chemotherapy for urothelial cancer

Abstract

In the beginning, the concept of adjuvant chemotherapy after surgery or other localized treatment modality was met with skepticism, especially among surgeons. Slowly, with earnest work from many-but notably the Milan Group in breast cancer; the National Surgical Adjuvant Breast and Bowel Project in colon cancer; and the International Adjuvant Lung Cancer Trial Collaborative Group, the Eastern Cooperative Oncology Group (ECOG), and others in lung cancer-a 4% to50% reduction in the risk of cancer recurrence was demonstrated with adjuvant, systemic therapy after surgery in patients who were stratified based on historic criteria and categorized as being at elevated risk of recurrence.1-3 Consequently, adjuvant therapy is now standard for patients with these cancers. Progress in defining the role of neoadjuvant, adjuvant, or adjunctive systemic therapies in genitourinary cancer has been uneven. The use of adjuvant chemotherapy in the most chemosensitive tumor, testicular cancer, has been well studied to the point that success against the cancer is almost universal. The goal now is not to over treat patients and expose too many to chemotherapy-associated morbidity with the use of risk-adapted surveillance strategies based on pathologic and serum marker criteria. In prostate cancer, adjuvant androgen deprivation is a standard of care for patients who have lymph node metastases at radical prostatectomy, whereas adjuvant radiation has benefit for patients with extracapsular extension, and adjunctive androgen deprivation is a standard for patients with high-risk, localized disease who receive radiation therapy as their primary treatment. The potential role of perioperative chemotherapy in prostate cancer is unclear. Renal cell cancer has suffered from a lack of drugs that are suitable for use in the adjuvant setting until the recent advent of agents targeting the vascular endothelial growth factor pathways.One of the great paradoxes of modern genitourinary cancer therapeutics is the relative lack of benefit for chemotherapy in the adjunctive setting for patients with bladder cancer who either undergo surgery or receive radiation. In advanced transitional-cell urothelial cancer, cisplatin-based chemotherapy has a response rate in excess of 45%, albeit with limited durability in many patients. 4 Concurrent cisplatin