High-risk bladder cancer: improving outcomes with perioperative chemotherapy
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REVIEW
High-risk bladder cancer: improving outcomes with perioperative chemotherapy Daniel Y.C. Heng • Jorge A. Garcia
Received: 10 January 2008 / Accepted: 17 March 2008 / Published online: 16 May 2008 © Springer-Verlag 2008
Abstract Despite treatment with radical cystectomy and pelvic lymph node dissection, muscle invasive bladder cancer has a relapse rate of 50%. Patients can develop regionally advanced or metastatic disease that ultimately leads to death. The addition of neoadjuvant or adjuvant chemotherapy to reduce the risk of relapse and death has been extensively studied over the past two decades. Two contemporary trials coupled with a recent meta-analysis evaluating neoadjuvant chemotherapy demonstrated a modest but real improvement in overall survival. This has made neoadjuvant chemotherapy a standard of care. Clinical trials evaluating adjuvant chemotherapy in patients with high-risk dis-
ease have been plagued with statistical flaws and have, therefore, been unable to define the survival impact of this approach. It is hoped that ongoing adjuvant trials that are powered to detect small but meaningful clinical differences will clarify the benefit of chemotherapy after cystectomy. Since there are theoretical advantages and disadvantages to each of these approaches, both are widely used in North America. The evidence behind each approach and potential future developments in this field will be described. Keywords Bladder cancer • Chemotherapy • Adjuvant • Neoadjuvant Introduction
J.A. Garcia (쾷) Associate Staff, Department of Solid Tumor Oncology Cleveland Clinic Taussig Cancer Institute 9500 Euclid Avenue/R35 Cleveland, Ohio 44195, USA e-mail: [email protected] D.Y.C. Heng • J.A. Garcia Departments of Solid Tumor Oncology and Urology, Taussig Cancer Institute and Glickman Urological Institute, Cleveland Clinic, Cleveland, OH, USA
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Bladder cancer is the second most common genitourinary cancer and is estimated to have caused 13,570 deaths in the United States in 2007 [1]. Most patients present with superficial disease, but tumors that invade the muscularis propria have a high preponderance to developing regionally advanced or metastatic disease. Although radical cystectomy with bilateral lymph node dissection is potentially curative and represents the standard of care in North America, the 5 year overall survival in post-cystectomy series is rather disappointing, ranging from 36%–65% [2–5]. Bladder transitional cell carcinoma (TCC) has demonstrated sensitivity to cisplatin-based chemotherapy. Several studies have demonstrated the clinical benefit of cisplatinbased regimens in advanced TCC. These observations have served as the rationale to evaluate systemic chemotherapy in the perioperative setting in patients with locally advanced disease in an attempt to decrease systemic progression. This review will illustrate the controversies surrounding the timing of chemotherapy in relation to cystectomy, the regimens in use, and how they translate into benefit for the patient.
Oncol Rev (2008) 2:4–8
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