Chemotherapy for invasive bladder cancer: neoadjuvant versus adjuvant.
Review
Overview
abstract
The treatment of a patient with an invasive bladder tumor is based on the original urologic assessment. The global recommendation of a single treatment plan such as radical surgery, chemotherapy, radiation, or variations thereof, for all patients is clearly an antiquated approach. Case selection criteria for each single or multimodality approach need to be defined. Neoadjuvant therapy has the advantage of an in vivo response evaluation and the potential for bladder preservation. However, before treatment, the therapeutic goal--bladder preservation, treatment of micrometastases, or both--should be outlined. Patients with T2 or T3a tumors can be considered for bladder salvage by chemotherapy alone, chemotherapy plus radiation therapy or, chemotherapy followed by partial cystectomy. For those with higher stage tumors, therapy is directed more to the treatment of micrometastases, with bladder preservation as a secondary goal. In most cases additional therapy directed at the primary is required and clinical understaging remains significant. For some patients, initial surgery with the definition of the prognosis on firm pathologic grounds, may represent a better strategy. Those with positive nodes should be offered chemotherapy in the postoperative setting. Refinements in the techniques of ileo neo-bladders are of importance in improving quality of life, but when used alone will not alter the natural history of the disease. Drug resistance remains a major therapeutic obstacle. More effective agents, and the prospective identification of intrinsic or acquired resistance, invasion, and metastatic potential are required to optimize therapy for an individual patient. Ultimately, large scale randomized trials will be required to negate the heterogeneity of this patient population. Only then will individualization of treatment be possible.
