Comparing the Outcomes of ddMVAC vs. GC before Cystectomy in Patients with Muscle Invasive Bladder Cancer - Expert Commentary

Patients with muscle-invasive bladder cancer  (MIBC) who are treated with neoadjuvant chemotherapy (NAC) before cystectomy have a survival advantage. Few studies comparing cancer control and survival outcomes for different NAC regimens exist.

New research published by Peyton et al. in JAMA Oncology analyzed the pathologic downstaging rates, complete response rates and overall survival in MIBC patients associated with different types of NAC. The investigators compared those who received gemcitabine with cisplatin to those who received a dose-dense combination of methotrexate, vinblastine, doxorubicin, and cisplatin (ddMVAC) before cystectomy. The cross-sectional analysis included 1113 MIBC patients who underwent cystectomy. Of these, 824 patients had MIBC and 332 (40.3%) received NAC. 

The investigators found that the downstaging rates for ddMVAC were 52.2% in comparison to 41.3% for gemcitabine-cisplatin, and 27.0% for gemcitabine with carboplatin. They also observed higher complete response rates (41.3%) for ddMVAC, compared to 24.5% for gemcitabine-cisplatin, and 9.4% for gemcitabine-carboplatin. These results were also confirmed by propensity score matching (OR, 1.52; 95%CI, 0.99-2.35). Moreover, the investigators found that the median overall survival was higher in patients who were treated with ddMVAC compared to other chemotherapy regimens. Although the risk of death was lower in the ddMVAC group than gemcitabine-cisplatin, it was not statistically significant in adjusted or propensity-matched models. 

The findings of this study are concordant with other retrospective analyses. Planned prospective head-to-head comparisons of ddMVAC and GC regimens in the neoadjuvant setting are expected provide additional data. 

Written by: Bishoy M. Faltas, MD, Weill Cornell Medicine, New York, NY 

Read The Abstract 

Peyton CC, Tang D, Reich RR, Azizi M, Chipollini J, Pow-Sang JM, Manley B, Spiess PE, Poch MA, Sexton WJ, Fishman M, Zhang J, Gilbert SM. JAMA Oncol. 2018 Aug 30. doi: 10.1001/jamaoncol.2018.3542.JAMA Oncol. 2018 Aug 30. doi: 10.1001/jamaoncol.2018.3542.