Perioperative chemotherapy for bladder cancer

Early Adjuvant Chemotherapy Improves Survival in Muscle Invasive Bladder Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate whether earlier administration of adjuvant chemotherapy (AC) can significantly augment survival rates in muscle-invasive bladder cancer.

METHODS

We systematically searched PubMed, Cochrane Central, Scopus, and Web of Science library databases for original articles that looked at timing to AC after radical cystectomy. Heterogeneity was assessed using Higgins I2%, with values over 50% considered heterogeneous and analyzed with a random effects model; otherwise, a fixed effects model was used. Studies were stratified based on the cutoff time used for administering AC. Two primary cutoffs were employed: 45 days and 90 days. Immediate AC was defined as chemotherapy administered before the predefined cutoff, while delayed AC was defined as chemotherapy administered after this cutoff. Comparisons were made between immediate versus delayed.

RESULTS

A total of 5 studies were included. Overall survival (OS) was reported in all of the studies. The meta-analysis showed that immediate AC significantly improved OS, with a hazard ratio (HR) of 1.20 [1.06, 1.36], P=.004. When stratifying by the timing of therapy, starting chemotherapy within 45 days resulted in a greater improvement in survival (HR 1.27 [1.02, 1.59], P=.03) compared to starting within 90 days (HR 1.17 [1.00, 1.36], P=.04).

CONCLUSION

The findings of this systematic review and meta-analysis emphasize that the timing of AC post-radical cystectomy significantly influences survival outcomes in patients with MIBC. The benefits of early AC initiation underscore its potential in mitigating disease progression and improving long-term survival rates.

Does Time to Adjuvant Chemotherapy after Radical Cystectomy Affect Survival in Muscle Invasive Bladder Cancer? A Systematic Review

(1) Purpose: To assess the survival benefit for different times to adjuvant chemotherapy after a radical cystectomy. (2) Materials and Methods: We systematically searched PubMed®, Cochrane Central®, Scopus®, and Web of Science® library databases for original articles that looked at timing to adjuvant chemotherapy after radical cystectomy. Primary endpoints were five-year survival, progression free survival, and overall survival. Available multivariable hazard ratios and corresponding 95% CIs were included in the qualitative analysis. The risk of bias was completed for nonrandomized studies. (3) Results: Using PRISMA guidelines, our electronic search resulted in a total of 1862 records. After a detailed review, we selected four studies that addressed the impact of the timing of adjuvant chemotherapy for patients who underwent radical cystectomy. (4) Conclusion: A survival benefit was seen with an earlier administration of adjuvant chemotherapy, albeit a benefit persists for delayed chemotherapy post-radical cystectomy. A safe and ethical approach at this time would be to administer adjuvant chemotherapy as early in the postoperative period as possible, given the known survival benefit of such therapy (9-11% absolute survival benefit at five years).

Update on the management of invasive bladder cancer 2012

Muscle-invasive bladder cancer is a deadly disease for which a number of new approaches have become available to improve prognosis. A recent review emphasized the importance of timely indication of surgery and highlighted current views regarding the adequate extent of the surgery and the importance of lymph node dissection. Furthermore, treatment using neoadjuvant and adjuvant systemic chemotherapy has become more prominent, while cystectomy and diversion should be conducted only in experienced centers. Optimal methods of urinary diversion and the use of robot-assisted laparoscopic cystectomy require further study.

Role of systemic peri-operative chemotherapy in management of transitional cell carcinoma of bladder

Bladder cancer has variable biological behavior pattern in different individuals and the debate regarding peri-operative use of systemic chemotherapy with the surgical management remains. The optimal treatment strategy, regimen and the timing of peri-operative chemotherapy are not yet known. Here we review the existing literature for the use of systemic peri-operative chemotherapy in management of advanced bladder cancer.

The effect of age on bladder cancer incidence, prognosis and therapy

Age is now widely accepted as the single greatest risk factor for developing urothelial carcinoma of the bladder (UCB). The aim of this article is to assess the incidence, prognosis and therapy of UCB in the elderly. Using MEDLINE, we performed a search of the literature between January 1966 and July 2009. The link between aging and cancer is more complex than the simple passage of time; certain genes may be activated while others may be suppressed with advancing age. Treatments for nonmuscle-invasive UCB are generally well-tolerated by the elderly. However, several studies have demonstrated a lower response rate to intravesical immunotherapy in the elderly. While elderly patients have a higher rate of perioperative complication and mortality after radical cystectomy, the difference is too small and insufficient to avoid radical cystectomy in these patients. Similarly, in certain selected cases, centers of excellence report similar complication rates in elderly patients, regardless of the type of urinary diversion. The optimal application of perioperative chemotherapy is dependent on the degree of compromise of the organ systems through comorbid conditions and physiologic deterioration. Restrictive case selection and proactive postoperative rehabilitation are important for elderly patients to obtain good results. Age alone does not preclude optimal treatment for patients with aggressive UCB. Radical surgery, urinary diversion and systemic chemotherapy are feasible, safe and efficacious in the treatment of adequately selected elderly UCB patients. It is imperative that healthcare practitioners and researchers from disparate disciplines collectively focus their efforts to appropriately meet the multifaceted medical and psychosocial needs of the elderly.

The effect of age and gender on bladder cancer: a critical review of the literature

While patient age and gender are important factors in the clinical decision-making for treating urothelial carcinoma of the bladder (UCB), there are no evidence-based recommendations to guide healthcare professionals. We review previous reports on the influence of age and gender on the incidence, biology, mortality and treatment of UCB. Using MEDLINE, we searched for previous reports published between January 1966 and July 2009. While men are three to four times more likely to develop UCB than women, women present with more advanced disease and have worse survival rates. The disparity among genders is proposed to be the result of a differential exposure to carcinogens (i.e. tobacco and chemicals) as well as reflecting genetic, anatomical, hormonal, societal and environmental factors. Inpatient length of stay, referral patterns for haematuria and surgical outcomes suggest that inferior quality of care for women might be an additional cause of gender inequalities. Age is the greatest single risk factor for developing UCB and dying from it once diagnosed. Elderly patients face both clinical and institutional barriers to appropriate treatment; they receive less aggressive treatment and sub-therapeutic dosing. Much evidence suggests that chronological age alone is an inadequate indicator in determining the clinical and behavioural response of older patients to UCB and its treatment. Epidemiological and mechanistic molecular studies should be encouraged to design, analyse and report gender- and age-specific associations. Improved bladder cancer awareness in the lay and medical communities, careful patient selection, treatment tailored to the needs and the physiological and physical reserve of the individual patient, and proactive postoperative care are particularly important. We must strive to develop transdisciplinary collaborative efforts to provide tailored gender- and age-specific care for patients with UCB.

Bladder cancer in the elderly

INTRODUCTION

Age is now widely accepted as the greatest single risk factor for developing bladder cancer, and bladder cancer is considered as primarily a disease of the elderly. Because of the close link between age and incidence of bladder cancer, it can be expected that this disease will become an enormous challenge with the growth of an aging population in the years ahead.

METHODS

Using MEDLINE, a search of the literature between January 1966 and July 2007 was performed to describe normative physiologic changes associated with aging, elucidate genetic and epigenetic alterations that associate aging with bladder cancer and its phenotypes; and to characterize how aging influences efficacies, risks, side effects, and potential complications of the treatments needed for the various stages of bladder cancer.

RESULTS

We discuss influence of aging on host physiology, genetic and epigenetic changes, environmental influences, and host factors in the development and treatment of bladder cancer. Treatments with intravesical bacille Calmette Guerin, radical cystectomy, and perioperative chemotherapy are less well tolerated and have poorer response in elderly patients compared with their younger counterparts. Elderly patients face both clinical and broader institutional barriers to appropriate treatment and may receive less aggressive treatment and sub-therapeutic dosing. However, when appropriately selected, elderly patients tolerate and respond well to cancer treatments.

CONCLUSIONS

The decision to undergo treatment for cancer is a tradeoff between loss of function and/or independence and extension of life, which is complicated by a host of concomitant issues such as comorbid medical conditions, functional declines and "frailty", family dynamics, and social and psychologic issues. Chronological age should not preclude definitive surgical therapy. It is imperative that healthcare practitioners and researchers from disparate disciplines collectively focus efforts towards gaining a better understanding of what the consequences of bladder cancer and its treatments are for older adults and how to appropriately meet the multifaceted medical and psychosocial needs of this growing population.

Potential impact of postoperative early complications on the timing of adjuvant chemotherapy in patients undergoing radical cystectomy: a high-volume tertiary cancer center experience

BACKGROUND

Perioperative cisplatin combination chemotherapy is associated with a survival benefit in patients with invasive bladder cancer (BCa). However, in a recent report from the National Cancer Database (NCDB), only 11.6% of stage III BCa patients received perioperative chemotherapy, the majority in the adjuvant setting.

OBJECTIVE

We explore the impact of postoperative complications on the timing of adjuvant chemotherapy.

DESIGN, SETTING, AND PARTICIPANTS

An independent review board approved the review of 1142 consecutive radical cystectomies (RC), and data from these cases were entered into a prospective complication database (1995-2005) which was utilized and retrospectively reviewed for accuracy at a single, academic, tertiary cancer center.

INTERVENTIONS

All patients underwent RC/urinary diversion by high-volume, fellowship-trained, urologic oncologists.

MEASUREMENTS

All complications within 90 d of surgery were defined and graded using a five-grade modification of the original Clavien system utilized at Memorial Sloan-Kettering Cancer Center and stratified into 11 categories. Grade 2-5 complications typically prohibit starting adjuvant chemotherapy. Univariate and multivariable logistic regression were used to evaluate variables associated with complications.

RESULTS AND LIMITATIONS

Overall, 64% (735 of 1142 patients) experienced one or more complications, of which 83% (611 of 735) were grade 2-5. Furthermore, 57% of grade 2-5 complications (347 of 611) occurred between discharge and 90 d, 38% (233 of 611) within 6 wk, and 19% (114 of 611) between 6 wk and 12 wk, the general time frame for adjuvant chemotherapy. Overall, 26% (298 of 1142 patients) required readmission. Surgical morbidity at a high-volume tertiary cancer center may not reflect the case mix or surgical experience seen in the community setting.

CONCLUSION

This series demonstrates that 30% of patients (347 of 1142) undergoing RC may not have been able to receive adjuvant chemotherapy due to postoperative complications. This information should be taken into consideration when planning multimodal therapy and further supports the use of perioperative chemotherapy in the neoadjuvant setting.

Bladder cancer

PURPOSE OF REVIEW

This article will review the diagnosis and management of bladder cancer at each stage, from superficial to metastatic disease with an emphasis on recent developments over the last year.

RECENT FINDINGS

Bacille Calmette-Guerin is the most effective therapy for carcinoma in situ. All patients who receive intravesical therapy with bacille Calmette-Guerin should be considered for ongoing maintenance therapy. The management of muscle invasive disease in the United States centers on radical cystectomy with bilateral pelvic lymphadenectomy. Areas of research include the optimal role for bladder preservation therapy, a growing experience in centers with laparoscopy, the effect of urinary diversion on quality of life, and the optimal standard for pelvic lymphadenectomy at surgery. The role of combination chemotherapy for advanced bladder cancer continues to evolve. Many questions remain unanswered including the relative value of neoadjuvant versus adjuvant chemotherapy for locally advanced disease and optimal chemotherapy regimen.

SUMMARY

The detection of bladder cancer continues to rely on direct visualization with cystoscopy. Efforts are underway to improve the utility of urinary markers and cystoscopy through fluorescence endoscopy. The management of superficial bladder cancer is based on transurethral resection of the tumor with perioperative intravesical instillation of chemotherapy strongly suggested for most patients. Risk stratifying patients with high-risk superficial bladder cancer remain a challenge and area of future research.

Bladder cancer angiogenesis and metastasis--translation from murine model to clinical trial

In the majority of cases, death from bladder cancer results from metastatic disease. Understanding the closely linked mechanisms of invasion, metastasis and angiogenesis in bladder cancer has allowed us to develop new therapeutic strategies that harbor the promise of decisive improvements in patient survival. The essential link between cell based experiments and the translation of novel agents into human patients with bladder cancer is the animal model. With emphasis on the orthotopic xenograft model, this review outlines some key mechanisms relevant to angiogenesis and the development of metastasis in bladder cancer. We highlight especially pathways related to MMP-9, IL-8, VEGF and EGFR. Most commonly, expression patterns of these markers in patients have correlated to disease progression and patient survival, which has led to laboratory investigations of these markers and eventually novel targeted therapies that are translated back into the clinic by means of clinical trials. Although imperfect in their translatability into clinical efficacy, animal models remain a critical tool in bladder cancer research.

Prediction of drug combination chemosensitivity in human bladder cancer

The choice of therapy for metastatic cancer is largely empirical because of a lack of chemosensitivity prediction for available combination chemotherapeutic regimens. Here, we identify molecular models of bladder carcinoma chemosensitivity based on gene expression for three widely used chemotherapeutic agents: cisplatin, paclitaxel, and gemcitabine. We measured the growth inhibition elicited by these three agents in a series of 40 human urothelial cancer cell lines and correlated the GI(50) (50% of growth inhibition) values with quantitative measures of global gene expression to derive models of chemosensitivity using a misclassification-penalized posterior approach. The misclassification-penalized posterior-derived models predicted the growth response of human bladder cancer cell lines to each of the three agents with sensitivities of between 0.93 and 0.96. We then developed an in silico approach to predict the cellular growth responses for each of these agents in the clinically relevant two-agent combinations. These predictions were prospectively evaluated on a series of 15 randomly chosen bladder carcinoma cell lines. Overall, 80% of the predicted combinations were correct (P = 0.0002). Together, our results suggest that chemosensitivity to drug combinations can be predicted based on molecular models and provide the framework for evaluation of such models in patients undergoing combination chemotherapy for cancer. If validated in vivo, such predictive models have the potential to guide therapeutic choice at the level of an individual's tumor.

Neoadjuvant chemotherapy for bladder cancer

The 30-45% failure rate after radical cystoprostatectomy mandates that we explore and optimize multimodal therapy to achieve better disease control in these patients. Cisplatin-based multi-agent combination chemotherapy has been used with success in metastatic disease and has therefore also been introduced in patients with high-risk but non-metastatic bladder cancer. There is now convincing evidence that chemotherapy given pre-operatively can improve survival in these patients. In this review we establish the need for peri-operative chemotherapy in bladder cancer patients and summarize the evidence for the efficacy of neoadjuvant chemotherapy. The advantages and disadvantages of neoadjuvant versus adjuvant chemotherapy are discussed, and the main shortcomings of both--treatment-related toxicity and the inability to prospectively identify likely responders--are presented. Finally, a risk-adapted approach to neoadjuvant chemotherapy is presented, whereby the highest risk patients are offered treatment while those unlikely to benefit are spared the treatment-related toxicity.

Impact of renal impairment on eligibility for adjuvant cisplatin-based chemotherapy in patients with urothelial carcinoma of the bladder

BACKGROUND

Perioperative cisplatin-based chemotherapy has shown benefit in patients with high-risk localized urothelial bladder cancer, but it is not widely used. Renal impairment may be a major factor limiting its use. The current study was designed to determine the proportion of patients ineligible to receive adjuvant cisplatin-based chemotherapy based on inadequate renal function alone.

METHODS

Patients who underwent radical cystectomy for urothelial cancer of the bladder with evidence of extravesical disease (> or =pT3 or any N+) were identified. Patients who received neoadjuvant chemotherapy were excluded. Serum creatinine immediately before and nadir serum creatinine after cystectomy were used to calculate creatinine clearance (CrCl) or glomerular filtration rate (GFR) using the Cockroft-Gault (CG), Jelliffe, and Modification of Diet in Renal Disease (MDRD) study formulas. A cutoff of CrCl <60 mL/min or GFR <60 mL/min/1.73 m2 was used to determine ineligibility for cisplatin-based chemotherapy. The proportion of patients ineligible by each formula was compared by univariate logistic regression. Univariate linear regression was performed to determine the effect of age on CrCl or GFR.

RESULTS

: Most patients were pT3 or greater; 39% were lymph node-positive. The overall proportion of patients ineligible for cisplatin-based chemotherapy was 28% by the CG formula, 52% by Jelliffe, and 24% by MDRD. Concordance between formulas was low. With all formulas the probability of ineligibility increased with age: by the CG equation, >40% of patients age >70 years were ineligible.

CONCLUSIONS

: The widespread use of cisplatin-based perioperative chemotherapy in patients with high-risk localized bladder cancer may be significantly limited by the high prevalence of baseline renal insufficiency in this population. This finding is most striking in the elderly. Better selection of patients who may safely receive cisplatin and more effective regimens devoid of cisplatin are required to optimize outcomes in this group of patients.