Use of Adjuvant Chemotherapy in Patients with Advanced Bladder Cancer after Neoadjuvant Chemotherapy

Abstract

Objectives:To compare the outcomes of adjuvant chemotherapy (AC) versus observation in patients with non-organ confined disease after neoadjuvant chemotherapy and radical cystectomy (RC).Materials and methods:Using the National Cancer Database, we identified patients who received NAC prior to RC and had advanced stage (pT3/4) or pathologically involved nodes (pN+) at the time of surgery from 2004–2013. We determined whether patients then received AC or were managed with observation only and used multivariable proportional hazards regression to estimate the impact of AC on overall survival.Results:Overall 34% (N = 705) of patients who received NAC and underwent RC were pT3/4 and/or pN+. Of these patients, 24% (N = 168) received subsequent chemotherapy and the rest were observed. Median survival for the entire cohort was 21 months (IQR 12–45). There was not a statistically significant difference in median survival between the AC and observation groups (23 months [IQR 14–46] versus 20 months [IQR 12–46], log-rank p = 0.52). On multivariate analysis there was no survival advantage for the AC cohort. Subgroup analysis of pN+ patients who received AC also did not show a survival advantage.Conclusions:Patients who are pT3/4 and/or pN+ after NAC and RC have a poor prognosis. The addition of AC does not seem to be beneficial. Further research should focus identifying patients who may benefit from additional chemotherapy.

The Role of Adjuvant Radiation Therapy in Locally Advanced Bladder Cancer

“…Moreover, patients treated with adjuvant chemotherapy were excluded from this study, suggesting that we do not know the role of adjuvant radiotherapy in patients in addition to adjuvant concurrent/sequential chemotherapy. While this study was not designed to determine the efficacy of adjuvant chemotherapy after neoadjuvant chemotherapy and cystectomy, there may be potential benefits for high risk patients [ 28, 29 ]; additional research is needed to further explore this question. Overall, these limitations do not diminish the need for further investigations of the role of adjuvant therapy for LABC.…”

Persistent muscle‐invasive bladder cancer after neoadjuvant chemotherapy: an analysis of Surveillance, Epidemiology and End Results‐Medicare data

“…The data for adjuvant chemotherapy after NAC + RC are not clear. A recent study of 705 patients found that those with non‐organ‐confined bladder cancer (pT3/pT4) at time of RC or node‐positive disease at time of RC, who received NAC, had no benefit to adjuvant chemotherapy . Currently, National Comprehensive Cancer Network recommendations for adjuvant treatment are for patients with pT3‐pT4 disease or nodal disease .…”

“…There is emerging research focused on improved patient selection for cisplatin‐based NAC via the use of tumour subtyping, genomics and biomarkers . Such strategies might not only enhance the benefit of NAC but also avoid undue harm or futility of NAC, especially in those who are likely to be non‐responders .…”

Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada

“…The use of AC after cisplatin-based NAC is not recommended, given conflicting results from observational series and lack of prospective data [30,[149][150][151][152][153][154]. Biologically, it is presumed tumor cells resistant to cisplatin-based NAC will also be refractory to AC.…”