Clinical role of additional adjuvant chemotherapy in patients with locally advanced urothelial carcinoma following neoadjuvant chemotherapy and cystectomy

Emerging Strategies in Adjuvant Immunotherapy: A Comparative Review of Bladder Cancer and Renal Cell Carcinoma Treatments

Recent progress in adjuvant immunotherapy offers hope for improving disease-free survival in high-risk bladder cancer (BC) and renal cell carcinoma (RCC). This review focuses on key trials such as CheckMate 274 and KEYNOTE-564, which show promising results with nivolumab in BC and pembrolizumab in RCC, including a 30% reduction in progression risk. Pembrolizumab also demonstrated overall survival (OS) benefit in RCC. The review also explores the potential of circulating tumor DNA (ctDNA) as a biomarker for better therapy selection and patient stratification. It emphasizes the need for ongoing research to establish survival benefits and suggests integrating biomarkers and risk stratification to optimize adjuvant immunotherapy in BC and RCC.

Influence of Neoadjuvant Chemotherapy on Survival Outcomes of Radical Cystectomy in Pathologically Proven Positive and Negative Lymph Nodes

Patients receiving neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) typically show better survival outcomes than those undergoing immediate surgery for muscle-invasive bladder cancer. However, most studies have not considered the lymph node (LN) status when evaluating NAC's survival benefits. This study sought to delineate the impact of NAC on patients based on their pathologically determined LN status at the time of RC. We examined data from 1395 patients treated at two departments between 1991 and 2022. Of them, 481 had positive LNs. A comparison of overall survival (OS) outcomes revealed that patients without LN involvement ((y)pN0) benefited from NAC with a hazard ratio (HR) of 0.692 (95% confidence interval [CI] 0.524-0.915). In contrast, patients with (y)pN+ showed no improvement with NAC (HR 0.927, 95%CI 0.713-1.205). Notably, patients treated with NAC for stage Collapse

Key Words

• bladder cancer
• neoadjuvant chemotherapy
• occult nodal disease
• overall survival
• radical cystectomy

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Affiliation(s)

Krystian Kaczmarek Department of Urology and Urological Oncology, Pomeranian Medical University, Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland
Bartosz Małkiewicz University Center of Excellence in Urology, Department of Minimally Invasive and Robotic Urology, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
Karolina Skonieczna-Żydecka Department of Biochemical Sciences, Pomeranian Medical University, Władysława Broniewskiego 24, 71-460 Szczecin, Poland
Artur Lemiński Department of Urology and Urological Oncology, Pomeranian Medical University, Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland Department of Biochemical Sciences, Pomeranian Medical University, Władysława Broniewskiego 24, 71-460 Szczecin, Poland

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Adjuvant pembrolizumab in genomically selected high-risk patients with muscle-invasive bladder cancer

INTRODUCTION

Patients with muscle-invasive urothelial bladder cancer post neoadjuvant cisplatin-based chemotherapy with pathologic advanced disease (ypT3, ypT4, ypN+) at radical cystectomy have a significantly worse five-year overall survival. There is currently no preferred adjuvant therapy to reduce risk of cancer recurrence in this high-risk patient cohort and surveillance remains the standard-of-care.

CASE REPORT

We present a case series of two patients who received cisplatin-based neoadjuvant chemotherapy and had pathologic node-positive urothelial carcinoma at the time of radical cystectomy. Tumor next generation sequencing revealed high mutational burden in both patients and positive PD-L1 in one patient.Management and outcome: Patients were treated with adjuvant pembrolizumab and experienced long-term disease free intervals.

DISCUSSION

Use of adjuvant checkpoint inhibitors in patients post neoadjuvant cisplatin-based chemotherapy with pathologic advanced disease at the time of radical cystectomy at high-risk of cancer recurrence sounds appealing. Careful patient selection based on tumor-specific genomic alterations may be key. Large trials addressing this question are ongoing.

The Prognosis and the Role of Adjuvant Chemotherapy for Node-Positive Bladder Cancer Treated with Neoadjuvant Chemotherapy Followed by Surgery

Purpose

This study aims to evaluate the prognosis of pathologically node-positive bladder cancer after neoadjuvant chemotherapy, the role of adjuvant chemotherapy in these patients, and the value of preoperative clinical evaluation for lymph node metastases.

Materials and Methods

Patients who received neoadjuvant chemotherapy followed by partial/radical cystectomy and had pathologically confirmed lymph node metastases between January 2007 and December 2019 were identified and analyzed.

Results

A total of 53 patients were included in the study. The median age was 61 years (range, 34 to 81 years) with males comprising 86.8%. Among the 52 patients with post-neoadjuvant/pre-operative computed tomography results, only 33 patients (63.5%) were considered positive for lymph node metastasis. Sixteen patients (30.2%) received adjuvant chemotherapy (AC group), and 37 patients did not (no AC group). With the median follow-up duration of 67.7 months, the median recurrence-free survival (RFS) and the median overall survival (OS) was 8.5 months and 16.2 months, respectively. The 2-year RFS and OS rates were 23.3% and 34.6%, respectively. RFS and OS did not differ between the AC group and no AC group (median RFS, 8.8 months vs. 6.8 months, p=0.772; median OS, 16.1 months vs. 16.3 months, p=0.479). Thirty-eight patients (71.7%) experienced recurrence. Distant metastases were the dominant pattern of failure in both the AC group (91.7%) and no AC group (76.9%).

Conclusion

Patients with lymph node-positive disease after neoadjuvant chemotherapy followed by surgery showed high recurrence rates with limited survival outcomes. Little benefit was observed with the addition of adjuvant chemotherapy.

Impact of Adjuvant Chemotherapy on Survival of Patients with Advanced Residual Disease at Radical Cystectomy following Neoadjuvant Chemotherapy: Systematic Review and Meta-Analysis

BACKGROUND

Cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) with pelvic lymph-node dissection is the standard treatment for cT2-4a cN0 cM0 muscle-invasive bladder cancer (MIBC). Despite the significant improvement of primary-tumor downstaging with NAC, up to 50% of patients are eventually found to have advanced residual disease (pT3-T4 and/or histopathologically confirmed nodal metastases (pN+)) at RC. Currently, there is no established standard of care in such cases. The aim of this systematic review and meta-analysis was to assess differences in survival rates between patients with pT3-T4 and/or pN+ MIBC who received NAC and surgery followed by adjuvant chemotherapy (AC), and patients without AC.

MATERIALS AND METHODS

A systematic search was conducted in accordance with the PRISMA statement using the Medline, Embase, and Cochrane Library databases. The last search was performed on 12 November 2020. The primary end point was overall survival (OS) and the secondary end point was disease-specific survival (DSS).

RESULTS

We identified 2124 articles, of which 6 were selected for qualitative and quantitative analyses. Of a total of 3096 participants in the included articles, 2355 (76.1%) were in the surveillance group and 741 (23.9%) received AC. The use of AC was associated with significantly better OS (hazard ratio (HR) 0.84, 95% confidence interval (CI) 0.75-0.94; p = 0.002) and DSS (HR 0.56, 95% CI 0.32-0.99; p = 0.05). Contrary to the main analysis, in the subgroup analysis including only patients with pN+, AC was not significantly associated with better OS compared to the surveillance group (HR 0.89, 95% CI 0.58-1.35; p = 0.58).

CONCLUSIONS

The administration of AC in patients with MIBC and pT3-T4 residual disease after NAC might have a positive impact on OS and DSS. However, this may not apply to N+ patients.

Epidemiology and treatment patterns for locally advanced or metastatic urothelial carcinoma: a systematic literature review and gap analysis

BACKGROUND: Several immuno-oncology (IO) agents targeting programmed death-1 or programmed death-ligand 1 (PD-1/L1) are approved second-line therapy options for patients with locally advanced or metastatic urothelial carcinoma (la/mUC) previously treated with platinum-based chemotherapy or first-line options in patients ineligible for cisplatin whose tumors express PD-L1 or for any platinum-based chemotherapy regardless of PD-L1 expression levels. However, literature on the epidemiology of la/mUC is limited, and real-world treatment patterns are not well established, especially with respect to therapies used following IO. OBJECTIVES: To (a) report the epidemiology of urothelial carcinoma (UC) and la/mUC; (b) identify and summarize the published literature on la/mUC treatment patterns, including IO and post-IO treatment; and (c) identify evidence gaps. METHODS: A systematic literature review was conducted using Cochrane dual-reviewer methodology and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Literature databases and selected congress abstracts (2017-2018) were searched for retrospective studies published January 2013-August 2018 in English reporting epidemiological and treatment data (all lines of therapy) for adult patients with la/mUC. RESULTS: Among 6,584 database references and 1,832 congress abstracts screened, 45 publications (29 manuscripts, 1 poster, 15 abstracts; reporting 37 unique studies) were retained. All studies related to treatment patterns, and the majority were from the United States (n = 17), Japan (n = 8), and the United Kingdom (n = 5). Epidemiological data were not identified among the searches thus online registries were leveraged. Among the identified publications, 21 (20 unique) reported on cisplatin versus non-cisplatin regimens, 14 (8 unique) on IO, and 9 (7 unique) on vinflunine. Cisplatin use varied both within and among countries (ranging from 18.4% in 1 U.S. study to 87.9% in 1 Japanese study). The use of IO was higher in later lines of therapy, ranging from 1.4% to 7.9% as first-line therapy to 57.8% as second-line and 64.4% as third-line therapy. Among studies reporting IO discontinuation rates, 41.4%-71% of patients were reported to discontinue IO across the studies, and the median time to discontinuation ranged from 2.7 to 5.8 months. Only 25%-35.5% of patients received subsequent therapy following IO discontinuation; post-IO treatments varied widely. CONCLUSIONS: Additional published data on the country-specific epidemiology of UC and la/mUC are needed, including rates of progression from early-stage disease to la/mUC. There was large variation in treatment rates, particularly cisplatin use, within and across countries. The few published real-world IO studies reported high levels of discontinuation with only a small percentage of patients receiving subsequent therapy. As IO therapies continue to be granted regulatory approval in countries outside the United States and novel therapies gain approval in the post-IO setting, the treatment paradigm for patients with la/mUC is shifting, and future studies with more recent data will be required. DISCLOSURES: This study was funded by Astellas/Seagen. Hepp is an employee of and owns stock in Seagen. Shah was a contractor for Astellas Pharma at the time of the study and owns stock in Pfizer. Smoyer is an employee and shareholder of Envision Pharma Group, paid consultants to Seagen. Vadagam was an employee of Envision Pharma Group, paid consultants to Seagen, at the time of the study. Parts of these data have been presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2019 Annual Meeting; May 18-22, 2019; New Orleans, LA.

Adjuvant chemotherapy in patients with locally advanced bladder cancer after neoadjuvant chemotherapy and radical cystectomy: a systematic review and pooled analysis

Background

Neoadjuvant chemotherapy (NAC) could ameliorate the stage of locally advanced bladder cancer (LABC) which is defined in pT3/T4 and/or pN+, improve overall survival (OS) before radical cystectomy (RC). However, for LABC, the decision to use adjuvant chemotherapy (AC) after NAC and RC is still controversial.

Methods

We performed a comprehensive search of the PubMed, Embase, and Cochrane Library databases for literature that reported prognosis after using AC following NAC and RC. Cumulative analyses of hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were performed. We performed all analyses by Review Manager software, version 5.3, and Stata 15.0.

Results

Six retrospective cohort studies were included, involving 4,346 patients. Pooled analysis results showed that using AC after NAC and RC can improve OS (HR =0.83, 95% CI: 0.74-0.94, P=0.002; I² =0%) and cancer-specific survival (CSS) (HR =0.56, 95% CI: 0.32-0.99, P=0.04; I² =0%) but cannot extend recurrence-free survival (RFS) (HR =0.52, 95% CI: 0.27-1.01, P=0.05; I² =53%) for LABC patients.

Conclusions

This pooled analysis shows that AC after NAC and RC can improve the prognosis for patients with LABC.

Adjuvant Treatment of Residual Disease Following Neoadjuvant Chemotherapy and Radical Cystectomy for Muscle Invasive Bladder Cancer

BACKGROUND: Cisplatin-based neoadjuvant chemotherapy (NAC) has shown overall survival benefit for patients with muscle invasive bladder cancer (MIBC). In contrast, there is limited data for adjuvant treatment options in patients with residual muscle invasive disease after NAC followed by radical cystectomy (RC). OBJECTIVE: This systematic review aims to give an overview of studies examining adjuvant treatment options for patients with residual MIBC at RC despite NAC. METHODS: We systematically searched the PubMed database and Clinicaltrials.gov (end point August 2019) for publications and registered trials combining NAC, RC, and adjuvant treatment options. RESULTS: After removal of duplicates, 659 articles and registered trials were further analyzed. Finally, 10 studies and 7 registered clinical trials met inclusion criteria. While 5 publications did not further characterize NAC and adjuvant regimens, the remaining 5 studies reported mainly platinum-based regimens. Altogether, the selected studies showed conflicting results regarding the potential role of adjuvant treatment strategies in the setting of residual disease after NAC and RC. CONCLUSION: Although there is an urgent need for adjuvant treatment options for patients with MIBC after NAC and residual muscle invasive disease at RC, there has been very limited evidence available. Inclusion of such patients into ongoing adjuvant clinical trials is urgently needed; active surveillance is strongly recommended in the absence of trials.

Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada

BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.

Management of Urothelial Bladder Cancer in Clinical Practice: Real-World Answers to Difficult Questions

Management of urothelial bladder cancer has historically been challenging as a result of a limited grasp of disease biology and few available systemic therapy options, mainly consisting of platinum-based chemotherapy. Improved understanding of molecular mechanisms underlying pathogenesis of muscle-invasive bladder cancer as well as their correlation with tumor behavior and response to treatment has emerged over the past few years. Remarkable therapeutic advances have been made with the introduction of checkpoint inhibitors, which have changed the course of this disease. Multiple agents with novel mechanisms of action are also actively being explored in ongoing clinical trials. These advances are exciting but may prove challenging in terms of how to apply this constantly evolving plethora of data to actual patients. This review addresses the gray areas and challenging questions that frequently arise in clinical practice.

Neoadjuvant therapy for muscle-invasive bladder cancer

INTRODUCTION

Muscle-invasive bladder cancer (MIBC) is generally a highly aggressive malignancy with early and mostly distant recurrences. Cisplatin-based combinations have been established as neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) providing overall survival as well as disease-free survival benefit. Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of metastatic urothelial carcinoma and are being tested in the neoadjuvant setting as well.

AREAS COVERED

This review covers the existing guidelines for the management of MIBC. It summarizes the use of different NAC regimens. It also discusses the published literature of ICIs in this setting and explores future perspectives.

EXPERT OPINION

Cisplatin-based NAC is the standard of care in MIBC prior to RC. Cisplatin-ineligible MIBC patients have not demonstrated to clearly benefit from a chemotherapy regimen and proceed directly to RC, although novel agents have been evaluated in this setting. Pembrolizumab and atezolizumab as monotherapy have shown feasibility and promising pathologic response rates. The combination of cisplatin-based chemotherapy with ICIs and chemotherapy-free ICI alone approaches are being investigated in randomized trials. Molecular subclassification and development of predictive biomarkers in MIBC will further help to identify optimal treatment strategies in these patients.

Adjuvant Chemotherapy vs Observation for Patients With Adverse Pathologic Features at Radical Cystectomy Previously Treated With Neoadjuvant Chemotherapy

Importance

Despite existing evidence of a benefit associated with cisplatin-based adjuvant chemotherapy (AC) after radical cystectomy (RC) for chemotherapy-naive patients with pT3/T4 and/or pN+ urothelial carcinoma of the bladder (UCB), to our knowledge, no studies have addressed the effectiveness of AC in those who received neoadjuvant chemotherapy (NAC) before surgery.

Objective

To assess the comparative effectiveness of AC vs observation for patients with pT3/T4 and/or pN+ UCB previously treated with NAC and RC.

Design, Setting, and Participants

This observational cohort study used the National Cancer Data Base (January 1, 2006, through December 31, 2012) to identify individuals who received NAC and RC followed by AC or observation for pT3/T4 and/or pN+ UCB.

Main Outcomes and Measures

After multiple imputation was used to handle missing data, inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed with a 6-month conditional landmark to compare overall survival (OS) among patients who received NAC and RC followed by AC vs observation. In addition, exploratory analyses were conducted to examine the heterogeneity of the treatment effect according to age (continuous), sex (female vs male), Charlson comorbidity index (≥1 vs 0), pT/N stage (pT3/T4N0 vs pTanyN+), and surgical margin status (positive vs negative) by testing interaction terms within the IPTW-adjusted Cox proportional hazards regression model.

Results

Of the 788 patients with pT3/T4 and/or pN+ UCB (mean [SD] age, 65.3 [9.4] years; 603 [76.5%] male and 185 [23.5%] female), 184 (23.4%) received NAC and RC followed by AC and 604 (76.6%) received NAC and RC followed by observation. The 6-month conditional landmark, IPTW-adjusted Kaplan-Meier curves showed that median OS was significantly longer for NAC and RC followed by AC (29.9 months; interquartile range, 15.1-85.4 months) vs NAC and RC followed by observation (24.2 months; interquartile range, 12.9-58.9 months) (P = .046). The 5-year IPTW-adjusted rates of OS were 36.8% for NAC and RC followed by AC vs 24.7% for NAC and RC followed by observation. In the IPTW-adjusted Cox proportional hazards regression analysis, NAC and RC followed by AC was associated with a significant OS benefit (hazard ratio, 0.78; 95% CI, 0.61-0.99; P = .046). Interaction term analyses indicated that the OS benefit of NAC and RC followed by AC decreased significantly with age (hazard ratio, 0.97; 95% CI, 0.95-0.99; P = .02), whereas no significant interaction was observed with sex (P = .82), Charlson comorbidity index (P = .51), pT/N stage (P = .95), and surgical margin status (P = .29).

Conclusions and Relevance

This study found that AC after NAC and RC may be associated with an OS benefit for patients with pT3/T4 and/or pN+ UCB. The present findings should be considered as preliminary evidence to conduct a randomized clinical trial to address this association.

Comparison of Adjuvant Chemotherapy for Upper Tract versus Lower Tract Urothelial Carcinoma: A Systematic Review and Meta-Analysis

Introduction

Principles of management for upper tract urothelial carcinoma (UTUC) are mostly derived from knowledge of lower tract urothelial carcinoma (LTUC), however recent research indicates that these may be disparate diseases. In this review, we sought to compare the responsiveness of these tumors to similar treatment, platinum-based chemotherapy used in the adjuvant setting.

Materials and Methods

PubMed, EMBASE, and Web of Science were searched using a systematic search strategy. Disease-free survival (DFS), cancer-specific survival (CSS) and overall survival (OS) in patients with LTUC and UTUC treated with adjuvant chemotherapy were compared. Review Manager V 5.3 was used for meta-analyses.

Results

Adjuvant chemotherapy was associated with improved DFS (HR 0.41, 95%CI 0.31-0.54), CSS (HR 0.29, 95%CI 0.17-0.50) and OS (HR 0.51, 95%CI 0.38-0.70) rates in LTUC. The effectiveness of adjuvant chemotherapy in UTUC was less pronounced with respect to DFS (HR 0.61, 95%CI 0.1-0.93) and CSS (HR 0.70, 95%CI 0.56-0.90) rates, and there was no effect on OS (HR 0.87, 95%CI 0.69-1.10). Differences in CSS and OS were significant (p < 0.0001) in favor of adjuvant chemotherapy for LTUC versus UTUC.

Conclusion

Despite similar histology, we found significant differences in responsiveness to adjuvant chemotherapy between LTUC and UTUC. This may add to the already growing knowledge that these are disparate diseases. Newer systemic treatments for urothelial carcinoma may prove more effective than platinum-based chemotherapy in the adjuvant setting for UTUC.

Incidence, Patterns, and Outcomes with Adjuvant Chemotherapy for Residual Disease After Neoadjuvant Chemotherapy in Muscle-invasive Urinary Tract Cancers

BACKGROUND

Patients with residual muscle-invasive urinary tract cancer after neoadjuvant chemotherapy (NAC) have a high risk of recurrence.

OBJECTIVE

To retrospectively evaluate whether additional adjuvant chemotherapy (AC) improves outcomes compared with surveillance in patients with significant residual disease despite NAC.

DESIGN, SETTING, AND PARTICIPANTS

We identified 474 patients who received NAC from the Retrospective International Study of Cancers of the Urothelium database, of whom 129 had adverse residual disease (≥ypT3 and/or ypN⁺).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Time to relapse (TTR) was the primary endpoint assessed starting from 2mo after surgery to minimize immortal time bias. Secondary endpoints included overall survival (OS), incidence of AC use, and chemotherapy patterns. Kaplan-Meier and Cox regression models estimated TTR, OS, and associations with AC, adjusting for the type of NAC, age, and pathological stage in multivariable analyses.

RESULTS AND LIMITATIONS

A total of 106 patients underwent surveillance, while 23 received AC. Gemcitabine-cisplatin was the most frequent regimen employed in both settings (30.4%), and the majority (82.6%) of the patients switched to a different regimen. Median follow-up was 30mo. Over 50% of patients developed a recurrence. Median TTR was 16mo (range: <1-108mo). Longer median TTR was observed with AC compared with surveillance (18 vs 10mo, p=0.06). Risk of relapse significantly decreased with AC when adjusted in multivariable analyses (p=0.01). The subgroup analyses of ypT4b/ypN⁺ patients (AC: 19; surveillance: 50) who received AC had significantly greater median TTR (20 vs 9mo; hazard ratio 0.43; 95% confidence interval: 0.21-0.89). No difference in OS was found. Limitations include the retrospective design.

CONCLUSIONS

The utilization of AC after NAC in patients with high-risk residual disease is not frequent in clinical practice but might reduce the risk of recurrence. Further investigation is needed in this high-risk population to identify optimal therapy and to improve clinical outcomes such as the ongoing adjuvant immunotherapy trials.

PATIENT SUMMARY

We found that administering additional chemotherapy in patients who had significant residual disease despite preoperative chemotherapy is not frequent in clinical practice. While it might reduce the risk of recurrence, it did not clearly increase overall survival. We encourage participation in the ongoing immunotherapy trials to see whether we can improve outcomes using a different type of therapy that stimulates the immune system.

The role of adjuvant chemotherapy in locally advanced bladder cancer

PURPOSE

The standard of care for locally advanced bladder cancer (LABC) is neoadjuvant chemotherapy followed by cystectomy. However, the role of adjuvant therapy is unclear. The purpose of this study was to evaluate the outcomes of adjuvant chemotherapy for patients with LABC following neoadjuvant chemotherapy and cystectomy, and to determine whether select patients may benefit from adjuvant chemotherapy.

METHODS

The National Cancer Data Base (NCDB) was queried (2004-2013) for patients with newly diagnosed pT3-4N0-3M0 bladder cancer that received neoadjuvant chemotherapy and cystectomy. Patients were divided into two groups based on the adjuvant therapy they received: chemotherapy alone or observation. Statistics included multivariable logistic regression to determine factors predictive of receiving adjuvant chemotherapy, Kaplan-Meier analysis to evaluate overall survival (OS) and Cox proportional hazards modeling to determine variables associated with OS.

RESULTS

Altogether, 2592 patients met inclusion criteria; 901 (34.8%) patients received adjuvant chemotherapy, while 1691 (65.2%) were observed. Patients treated with adjuvant chemotherapy were more likely to have positive margins were younger and more likely to receive treatment at a nonacademic facility. There was no difference in median OS between patients treated with or without adjuvant chemotherapy (22.6 vs. 21.1 months; p = .267). However, a longer median OS was observed with the use of adjuvant chemotherapy was observed among patients with N2-3 disease (17.5 vs. 14.4 months; p = .005) and positive surgical margins (16.7 vs. 12.2 months; p = .025). On multivariate analysis, advancing age, pT4 stage, positive N stage, positive margins and lower socioeconomic status were associated with worse OS.

CONCLUSIONS

In the largest study to date evaluating efficacy of adjuvant chemotherapy, while no difference in OS was observed for adjuvant chemotherapy in all patients, a longer OS was observed among patients with N2-3 disease or with positive surgical margins. Prospective studies are recommended to further evaluate these findings.

Peri-operative chemotherapy for muscle-invasive bladder cancer: status-quo in 2017

The role of perioperative chemotherapy associated with radical cystectomy (RC) for muscle-invasive bladder cancer has been analyzed in several landmark randomized controlled trials (RCTs) over the past decades. With regard to neoadjuvant chemotherapy (NAC), a meta-analysis of level 1 evidence and long-term results from the largest RCTs support its use, which is currently advocated as the standard of care by most of the clinical guidelines worldwide. However, with regard to the delivery of adjuvant chemotherapy (AC), evidence is more contentious. Specifically, several meta-analyses demonstrated a survival benefit associated with the use of cisplatin-based regimen but investigators identified multiple methodological limitations in most of included RCTs. Nonetheless, AC is currently considered for fit patients with adverse pathological features at RC. It is noteworthy that the delivery of such cytotoxic treatment after surgery may maintain significant anti-tumor activity even in those patients who previously received NAC. Finally, given its greater response rate, the methotrexate, vinblastine, adriamycin plus cisplatin combination remains preferentially considered in the neoadjuvant setting, while the gemcitabine plus cisplatin combination is more commonly delivered in the adjuvant setting because of its better toxicity profile. However, no prospective evidence comparing efficacy of both regimens for NAC or AC is currently available.

Use of Adjuvant Chemotherapy in Patients with Advanced Bladder Cancer after Neoadjuvant Chemotherapy

Objectives:

To compare the outcomes of adjuvant chemotherapy (AC) versus observation in patients with non-organ confined disease after neoadjuvant chemotherapy and radical cystectomy (RC).

Materials and methods:

Using the National Cancer Database, we identified patients who received NAC prior to RC and had advanced stage (pT3/4) or pathologically involved nodes (pN+) at the time of surgery from 2004–2013. We determined whether patients then received AC or were managed with observation only and used multivariable proportional hazards regression to estimate the impact of AC on overall survival.

Results:

Overall 34% (N = 705) of patients who received NAC and underwent RC were pT3/4 and/or pN+. Of these patients, 24% (N = 168) received subsequent chemotherapy and the rest were observed. Median survival for the entire cohort was 21 months (IQR 12–45). There was not a statistically significant difference in median survival between the AC and observation groups (23 months [IQR 14–46] versus 20 months [IQR 12–46], log-rank p = 0.52). On multivariate analysis there was no survival advantage for the AC cohort. Subgroup analysis of pN+ patients who received AC also did not show a survival advantage.

Conclusions:

Patients who are pT3/4 and/or pN+ after NAC and RC have a poor prognosis. The addition of AC does not seem to be beneficial. Further research should focus identifying patients who may benefit from additional chemotherapy.

Adverse Pathology After Neoadjuvant Chemotherapy and Radical Cystectomy: The Role of Adjuvant Chemotherapy

BACKGROUND

The current guidelines do not recommend adjuvant chemotherapy (AC) for patients with adverse pathologic findings after neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) for bladder cancer. We sought to evaluate the association of AC with overall survival (OS) in these patients.

MATERIALS AND METHODS

The National Cancer Database was used to identify patients with adverse pathologic findings (ypT3N0, ypT4N0, or ypTanyN1-N3) after NAC and RC for bladder cancer from 2006 to 2012. The clinicopathologic variables were abstracted, and the patients were stratified according to the receipt of AC. OS was estimated using the Kaplan-Meier method and log-rank test. Associations between AC and OS were evaluated in multivariable Cox proportional hazards regression models among all patients and stratified by pathologic classification.

RESULTS

A total of 1361 patients were identified: 444 (32.6%) with ypT3N0, 162 (11.9%) with ypT4N0, and 755 (55.5%) with ypTanyN1-N3. The median OS for the entire cohort was 22.9 months, which differed by pathologic classification: 34.6 months with ypT3N0, 21.4 months with ypT4N0, and 19.3 months with ypTanyN1-N3 (P < .01). AC was used in 328 patients (24.1%), and no difference in OS was observed by receipt of AC (24.6 months with AC vs. 22.0 months without; P = .18). On multivariable analysis, AC was not independently associated with OS (hazard ratio, 0.86; 95% confidence interval, 0.74-1.01; P = .06).

CONCLUSION

Patients with adverse pathologic findings at RC after previous NAC have a median OS of approximately 2 years, which was not significantly improved with AC. Clinical trials with newer systemic agents are warranted for patients in this setting to guide future therapy.