Neoadjuvant Chemotherapy with Docetaxel and Cisplatin in Patients with High-Risk Resectable Bladder Carcinoma: Long Term Results

Referral for "Neoadjuvant Chemotherapy" for Muscle-Invasive Bladder Cancer to a Multidisciplinary Board: Patterns, Management and Outcomes

Background

Utilization of neoadjuvant chemotherapy for the treatment of muscle invasive bladder cancer in everyday practice differs from that of clinical trials. We describe the patterns of referral for “neoadjuvant chemotherapy”, treatment and outcomes in a multidisciplinary tumor board.

Methods

This was an observational study. Patients referred for neoadjuvant chemotherapy received 4 cycles of dose-dense gemcitabine/cisplatin and were then assessed for definitive local therapy. Patients had a minimum follow-up of 2 years. Primary objective was a 3-year disease-free survival rate.

Results

Forty-six patients (clinical stages II: 28, IIIA: 9, IIIB: 4, IVA: 3, missing: 2) were included. Following chemotherapy, 30 underwent radical cystectomy, 8 radiotherapy and 8 no further therapy. Pathological downstaging was observed in 14 (46.6%) of the 30 patients who underwent radical cystectomy; clinical TNM staging was correlated with disease-free survival in the whole population, while clinical and pathological stages, as well as pathological downstaging, were correlated with disease-free survival in patients undergoing radical cystectomy. Three-year disease-free survival rates for the whole cohort and for patients undergoing radical cystectomy were 67.3% (95% confidence interval [CI]: 51–79.2) and 65.2 (95% CI: 44.9–79.6), respectively.

Conclusion

Real-world muscle invasive bladder cancer patients who receive neoadjuvant chemotherapy are characterized by more advanced diseases and less frequent radical surgery than those included in clinical trials. Nevertheless, outcomes were comparable and, therefore, offering patients with stage II–IVA muscle invasive bladder cancer neoadjuvant chemotherapy after assessment by multidisciplinary tumor boards should be strongly encouraged.

Modulation of the anti-cancer efficacy of microtubule-targeting agents by cellular growth conditions

Mitotic spindle-disrupting agents target and disrupt microtubule dynamics. These agents include clinically important chemotherapies, including taxanes (paclitaxel (Taxol), docetaxel (Taxotere)) and vinca alkaloids (vincristine (Oncovin), vinblastine). Taxanes are a standard component of treatment for many malignancies, often in conjunction with other cytotoxic agents. However, the optimal sequencing of these treatments and whether efficacy may be influenced by in vitro cellular growth conditions remain incompletely investigated. Yet such preclinical investigations may guide clinical decision making. We therefore studied the effect of cell density on rapid killing by paclitaxel and vincristine. Breast, ovarian and prostate cancer cells were sensitive to rapid killing by either agent when grown at low density, but were markedly resistant when grown at high density, i.e. nearly confluent. The resistance of densely growing cells to rapid killing by these drugs translated to increased clonogenic survival. Pretreatment of densely growing cancer cells with cisplatin followed by paclitaxel, partially reversed the treatment resistance. Gene ontology associations from microarray analyses of cells grown at low and high density, suggested roles for membrane signal transduction and adhesion, but potentially also DNA damage repair and metabolism. Taken together, the treatment resistance at higher cell density may be associated with a lower proportion of active cycling in cells growing at high density as well as transduction of survival signals induced by increased cell-cell adhesion. Collectively these findings suggest mechanisms by which growth conditions may contribute to resistance to rapid killing by microtubule-disrupting drugs.

Neoadjuvant chemotherapy in invasive bladder cancer

The role of neoadjuvant chemotherapy in muscle-invasive bladder cancer has been clarified by recent randomized studies and meta-analyses, which all showed that cisplatin-based, combination chemotherapy offers a significant survival advantage. Preoperative chemotherapy results in downstaging in a significant percentage of patients, which is an independent factor of favorable prognosis. Nevertheless, the optimal sequence of perioperative chemotherapy remains undefined. The authors examine the results of large Phase II and randomized studies as well as the role of neoadjuvant chemotherapy in the context of bladder preservation strategies. Finally, issues of improving therapeutic efficacy and directing clinical research are discussed.

Bladder cancer

PURPOSE OF REVIEW

This article reviews the recent literature concerning important issues in the management of patients with bladder cancer. A brief overview of all aspects of bladder cancer including the etiology, diagnosis, and treatment are discussed with a focus on recent advances.

RECENT FINDINGS

Bladder cancer is a significant cause of morbidity and mortality. The treatment for bladder cancer should be based on individual patient risk assessment and should include a multidisciplinary approach. In patients with superficial bladder cancer, research has focused on improving and optimizing intravesical therapy to reduce tumor recurrence and progression as well as on methods to better select the most appropriate treatment for patients with high-risk features. The important prognostic and therapeutic role of lymphadenectomy during radical cystectomy has become apparent and recent work has attempted to better define what should be considered the standard for lymph node dissection. Finally, in an attempt to improve survival, advances have been made using systemic chemotherapy in both the perioperative settings as well as for treatment of metastatic bladder cancer.

SUMMARY

Research continues to improve our understanding of bladder cancer. This ongoing investigation is currently being translated to the bedside with refinements in the diagnosis and treatment of patients with bladder cancer.

Adjuvant and Neoadjuvant Chemotherapy in Muscle Invasive Bladder Cancer: Literature Review

Radical cystectomy is the standard treatment for patients with clinically localized muscle invasive bladder cancer, providing a 5-year survival rate of approximately 50%. Failure to cure is often due to the presence of occult metastases beyond the margins of local therapy, indicating a need for eradication of micrometastatic disease with systemic treatment, in order to improve survival. Combined chemotherapy regimens, such as methotrexate-vinblastine-cisplatin (CMV), methotrexate-vinblastine-cisplatin-doxorubicin (M-VAC) and gemcitabine-cisplatin (GC) have already demonstrated their effectiveness in patients with advanced or metastatic disease and have been considered as appropriate regimens in the peri-operative setting. Large randomized studies with a prolonged follow-up have been able to confirm a modest survival benefit with neoadjuvant therapy. A recent meta-analysis, including all previous reported randomized trials, concluded that neoadjuvant chemotherapy administration provides a significant survival benefit and can be administered without adverse outcomes resulting from delayed local therapy. Adjuvant chemotherapy trials, although promising, have failed to show statistically improved survival, mostly due to small sample sizes and absent or inconclusive data on overall survival. A multi-center randomized-controlled trial is currently ongoing, in order to elucidate the role of post-operative chemotherapy administration.