Expert Commentary: Adjuvant chemotherapy in patients with urothelial carcinoma and adverse pathologic features receiving prior neoadjuvant chemotherapy and radical cystectomy

Neoadjuvant chemotherapy is a standard of care for patients with cisplatin-eligible muscle-invasive urothelial carcinoma. For patients who do not receive neoadjuvant chemotherapy, there is evidence of a benefit associated with cisplatin-based adjuvant chemotherapy after radical cystectomy for patients with pT3/T4 and/or pN+ bladder cancer. It is unknown whether additional adjuvant chemotherapy is beneficial for patients with adverse pathological features after neoadjuvant chemotherapy and radical cystectomy. 

A recent study by Seisen et al. published in JAMA Oncology addressed this question using a retrospective examination of the National Cancer Data Base. The investigators identified individuals who received neoadjuvant chemotherapy and radical cystectomy followed by either adjuvant chemotherapy or observation for pT3/T4 and/or pN+ urothelial carcinoma of the bladder. 

The study identified 788 patients with pT3/T4 and/or pN+ urothelial bladder cancer including 184 patients who received neoadjuvant chemotherapy followed by radical cystectomy and adjuvant chemotherapy and 603 patients who received only observation after neoadjuvant chemotherapy and radical cystectomy .The median overall survival was significantly longer for patients who received adjuvant chemotherapy following neoadjuvant chemotherapy   (29.9 months; interquartile range, 15.1-85.4 months) vs those who received neoadjuvant chemotherapy and radical cystectomy and observation (24.2 months; interquartile range, 12.9-58.9 months) (P = .046). 

This study suggests that adjuvant chemotherapy in patients with urothelial carcinoma and adverse pathologic features is beneficial even in patients treated with prior neoadjuvant chemotherapy and radical cystectomy. This finding should be understood in the context of the retrospective observational design of the present study. The magnitude of the clinical benefit observed in this study was sizeable. This therapeutic hypothesis should be tested in a randomized prospective trial. 

Written By: Bishoy Faltas, MD

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References:
Seisen T, Jamzadeh A, Leow JJ, Rouprêt M, Cole AP, Lipsitz SR, Kibel AS, Nguyen PL, Sun M, Menon M, Bellmunt J, Choueiri TK, Trinh QD. Adjuvant Chemotherapy vs Observation for Patients With Adverse Pathologic Features at Radical Cystectomy Previously Treated With Neoadjuvant Chemotherapy. JAMA Oncol. 2017 Aug 24. doi: 10.1001/jamaoncol.2017.2374
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