Original StudyAdjuvant Chemotherapy Is Possibly Beneficial for Locally Advanced or Node-Positive Bladder Cancer
Introduction
Urinary bladder cancer is the second most common cancer of the genitourinary system.1 An estimated 386,300 new cases and 150,200 deaths from bladder cancer occurred in 2008 worldwide.1 Radical cystectomy (RC) with pelvic lymph node dissection is a standard treatment for muscle-invasive and high-risk non–muscle-invasive bladder cancer.2 Despite the advances in surgical technique and patient selection, the risk of disease recurrence remains high; the 5-year recurrence-free survival (RFS) and overall survival (OS) after RC are reportedly 48% to 70% and 57% to 60%, respectively.3, 4, 5 Once patients experience recurrence after RC, their median survival time (MST) is approximately 15 months,6 and even shorter if they do not undergo salvage chemotherapy.7
Postoperative cisplatin-based systemic chemotherapy has been used to prevent recurrence.8 Although 2 previous randomized controlled trials (RCTs) showed a survival benefit for presurgical chemotherapy (neoadjuvant chemotherapy [NAC]),9, 10 it has not been widely adopted in practice.8 In contrast, postoperative systemic chemotherapy (adjuvant chemotherapy [AC]) has been used more often; David et al reported that in stage III bladder cancer, NAC and AC are applied in 1.4% and 10.4% of cases, respectively.11 A recent meta-analysis of 9 RCTs including 945 participants revealed a statistically significant benefit of AC on OS in muscle-invasive bladder cancer (hazard ratio [HR], 0.77; 95% confidence interval, 0.59-0.99; P = .049).12 However, most RCTs failed to prove the benefit of AC, and the optimal targets of AC have never been identified.13, 14, 15
In our institution, 3 cycles of cisplatin-based AC have been offered to patients with non–organ-confined bladder cancer (pT3-4 or pN1-3, or both). In this study, the outcomes were compared between patients with non–organ-confined bladder cancer receiving AC and those not receiving AC, and the predictors of survival benefit were analyzed.
Section snippets
Patients and Methods
This study was approved by our institutional review board (No. 3124). We reviewed medical records of all patients undergoing RC with curative intent at our institution from 1990 to 2012 and collected data for locally advanced (pT3-4) or node-positive (pN1-3) disease, or both, for the present study. Patients who received NAC or perioperative radiotherapy or those with early recurrence or mortality (within 8 weeks after RC) were excluded. It has been our policy to recommend 3 cycles of AC for
Results
Of the 187 patients undergoing RC, 64 were identified as having non–organ-confined bladder cancer. Three patients were excluded from the analysis because of early recurrence (n = 2) and postoperative mortality (n = 1). Of the remaining 61 patients, 39 (64%) received AC after RC (AC group), and 22 (36%) did not (non-AC group) because they declined AC treatment (n = 10), had a protracted recovery after RC (n = 5), or had insufficient renal function (n = 3), comorbidities (n = 2), or advanced age
Discussion
The role of adjunct chemotherapy with RC in the treatment of muscle-invasive bladder cancer remains controversial.8 At our institution, all patients with locally advanced or node-positive bladder cancer (pT3-4 or N+, or both) are offered 3 courses of cisplatin-based AC, although approximately one third decline treatment. In this study, comparing the prognoses of those receiving AC (AC group) and those not receiving AC (non-AC group), we found a significant survival advantage for the AC group.
Conclusion
In summary, our results suggest that postoperative cisplatin-based AC gives patients a survival advantage in locally advanced or node-positive bladder cancer, especially in node-positive cases. Further clinical trials targeting such patients are warranted.
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