Perioperative Chemotherapy for High-Risk Bladder Cancer Improves Survival but Is Not Routinely Administered
A recent study published in Cancer found that, contrary to treatment guidelines for high-risk bladder cancer, neoadjuvant chemotherapy is not commonly used in routine clinical practice. Utilization of adjuvant chemotherapy was found to be increasing over time and was associated with a substantial survival benefit in patients with muscle-invasive bladder cancer. However, only 23% of patients with resected muscle-invasive bladder cancer received any form of perioperative chemotherapy.
Clinical trials have shown that survival is improved in patients with muscle-invasive bladder cancer who are given neoadjuvant chemotherapy before surgery, but there is less evidence about whether adjuvant chemotherapy also improves survival. To investigate the use of perioperative chemotherapy in this disease, Christopher Booth, MD, FRCPC, of the Queen’s University Cancer Research Institute in Canada, and colleagues examined records pertaining to all 2,944 patients who underwent cystectomy for muscle-invasive bladder cancer in Ontario between 1994 and 2008.
Study Results
Use of chemotherapy before surgery remained stable (an average of 4% of patients) over the study period, a surprising finding given the evidence that this is a standard of care that has been demonstrated to improve survival. The use of chemotherapy after surgery increased over time: 16% of patients received adjuvant chemotherapy in 1994 to 1998, 18% in 1999 to 2003, and 22% in 2004 to 2008 (P = .001). Advanced-stage (odds ratio [OR] = 1.83, 95% confidence interval [CI] = 1.38–2.46) and node-positive disease (OR = 8.10, 95% CI = 6.20–10.7) and the presence of lymphovascular invasion (OR = 1.53, 95% CI = 1.11–2.15) were associated with greater use of adjuvant chemotherapy.
Five-year overall survival and cancer-specific survival for all patients was 29% (95% CI = 28%–31%) and 33% (95% CI = 31%–35%), respectively. After controlling for patient- and disease-related characteristics, study results showed that use of adjuvant chemotherapy was associated with improved overall survival (HR = 0.71, 95% CI = 0.62–0.81) and cancer-specific survival (HR = 0.73, 95% CI = 0.64–0.84).
“Results from our study demonstrate that chemotherapy given after surgery improves patient survival—probably on the same order of magnitude as chemotherapy before surgery,” said Dr. Booth. “Patients having surgery for bladder cancer should have chemotherapy, either before or after surgery. Efforts are needed to improve uptake of this treatment, which appears to be vastly underutilized.”
Dr. Booth is the corresponding author for the Cancer study.
The study was supported by Cancer Care Ontario, the Canadian Foundation for Innovation, and the Institute for Clinical Evaluative Sciences. The study authors reported no potential conflicts of interest.
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