The Effect of Neoadjuvant Chemotherapy on Perioperative Outcomes in Patients Who Have Bladder Cancer Treated With Radical Cystectomya Population-Based Study

Editorial

We read with interest the excellent report conducted by Gandaglia et al. [1]. Who determined the safety of the use of neoadjuvantchemotherapy before Radical Cystectomy (RC) in patients who have Muscle-Invasive Bladder Cancer (MIBC). The authors claimed the use of neoadjuvant chemotherapy is not associated with higher perioperative morbidity or mortality and should encourage wider use of neoadjuvantchemotherapy when clinically indicated. This study adds to the body of literature regarding the MIBC treatment, however, we would like to draw the attention of readers to some specific limitations that were not mentioned in the paper.

Standards of diagnosis, patient care, and surgery have changed over this long period of patient entry. With the increased adoption of minimally invasive approaches, the use of neoadjuvantchemotherapy for bladder cancer also demonstrated an increase trend [2]. That means that a higher proportion of the patients received neoadjuvantchemotherapy were treated with advanced medical care including minimally invasive approaches (e.g. laparoscopic cystectomy). Apparently, equivalent perioperative results could also attribute to the medical advancements [3]. Therefore, potential effect of bias could be introduced into this study.

Considerable patients treated with cisplatin based neoadjuvantchemotherapy before RC underwent severe hematologic or gastrointestinal side-effects [4,5]. Not just the perioperative morbidity and mortality, the low utilization of neoadjuvant chemotherapy also attributed in part to patient/physician choice and the advanced age, which often have multiple comorbidities including renal and/or cardiac dysfunction. Furthermore, a sizable proportion of patients received neoadjuvantchemotherapy did not accomplish the planned cystectomies [6], which may partially attribute to the impaired performance status. Therefore, we believe the “no significant differences of perioperative morbidity and mortality between the two groups” may not persuade the urologists to use of neoadjuvantchemotherapy more widely before RC.

Nonetheless, substantial data confirmed the overall survival advantage of neoadjuvantchemotherapy for patients with MIBC. We just kindly remind the readers that neoadjuvant chemotherapy should be carefully used and the patients should be carefully monitored. Optimal dosing schedule, appropriate patients, as well as acceptable regimens remain to be established in further studies.

References

1. GandagliaG, Ioana Popa a c, Firas Abdollah b, Jonas Schiffmann , Shahrokh Shariat e, Alberto Briganti, et al. The Effect of Neoadjuvant Chemotherapy on Perioperative Outcomes in Patients Who Have Bladder Cancer Treated with Radical Cystectomy: A Population-based Study. Eur. Urol. 2014; 66: 561-568.
2. Tang K, Li H, Xia D, Hu Z, Zhuang Q, Liu J, et al. Laparoscopic versus Open Radical Cystectomy in Bladder Cancer: A Systematic Review and Meta-Analysis of Comparative Studies. PLoS One. 2014; 9: 95667.
3. Liew MS, Azad A, Tafreshi A, Eapen R, Bolton D, Davis ID, et al. USANZ: Time-trends in use and impact on outcomes of perioperative chemotherapy in patients treated with radical cystectomy for urothelial bladder cancer. Bju Int. 2013; 112: 74-82.
4. Grossman HB, Ronald B Natale, Catherine M Tangen, Speights VO, Nicholas J Vogelzang, Donald L Trump, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N. Engl. J. Med. 2003; 349: 859-866.
5. Meeks JJ, Bellmunt J, Bochner BH, Clarke NW, Daneshmand S, Galsky MD, et al. A systematic review of neoadjuvant and adjuvant chemotherapy for muscle-invasive bladder cancer. Eur. Urol.2012; 62: 523-533.
6. Sternberg CN, Parmar MK. Neoadjuvant chemotherapy is not (yet) standard treatment for muscle-invasive bladder cancer. J.Clin.Oncol. 2001; 19: 21-26.