Outcomes of Neoadjuvant Chemotherapy in Invasive Urothelial Carcinoma - Expert Commentary
The investigators analyzed 513 patients who underwent RC for cT2-4N0-3M0 bladder cancer between 2010 and 2017. Patients were categorized into neoadjuvant/induction chemotherapy followed by radical cystectomy (NAIC + RC) (175 patients, 34.1%) and upfront radical cystectomy (RC) (338 patients, 65.9%) groups.
Significant baseline differences were observed between groups. NAIC+RC patients were younger (62.5 vs. 67.8 years), had lower Charlson comorbidity scores, and presented with higher clinical T and N stages (P<.001).
The median overall survival (mOS) was 60.5 months for NAIC+RC and 49.4 months for upfront RC (P=.171). In patients with residual muscle-invasive and/or node-positive disease (rMIBC), survival initially appeared inferior after NAIC+RC. However, the clinical stage distribution between groups was imbalanced, with only 3% versus 49% cT2N0 patients and 47% versus 9% cT4b and/or N+ patients in the NAIC+RC versus upfront RC groups, respectively. After adjusting for clinical T and N stages, age, and comorbidity scores in multivariable analysis, upfront RC was associated with worse overall survival (HR 1.52, [95% CI, 1.11-2.10], P=.009). NAIC+RC increased the likelihood of pathological complete response (28% vs. 8.6%) and complete downstaging (38.3% vs. 21.6%) compared to upfront RC.
This work suggests that the observed inferior survival in patients with rMIBC after NAIC+RC resulted from high-risk preoperative characteristics, including clinical stage. Importantly, NAIC before RC was associated with superior oncological outcomes when correcting for these characteristics. With recent developments in neoadjuvant therapy, it is important to continue to study how preoperative factors, including disease stage and histology, will affect response rates.
Written by: Bishoy M. Faltas, MD, Director of Bladder Cancer Research, Englander Institute for Precision Medicine, Weill Cornell Medicine
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