Dr. North presents a well-written dissertation that stresses the importance of a multidisciplinary approach to patients with muscle-invasive bladder cancer and also points out that neoadjuvant chemotherapy may not be the approach for everyone undergoing radical cystectomy.
Although Dr. North's concept of an in vivo presurgical “trial of chemotherapy” is an appealing model, it may be impractical and unfeasible. This paradigm requires 1) exceptional imaging that is currently limited even in its ability to stage patients; and 2) ample and flexible operating room time to promptly book patients who are chemotherapy nonresponders.
The most compelling advantages of adjuvant therapy include the optimal determination of metastatic risk based on pathological factors and minimizing the risk of tumour spread with the immediate removal of the primary tumour. Hence, adjuvant chemotherapy minimizes potential overtreatment and maximizes treatment in those who may benefit the most. In their review of the ABC meta-analysis, Sternberg and Collette1 point out the possibility of overtreatment in a neoadjuvant approach — 20 patients are required to obtain a survival gain at 5 years in 1 patient.
Ultimately, perioperative chemotherapy is an attractive concept. The debate about whether chemotherapy is better before or after radical cystectomy conceptually centres on which tumour one wants to treat immediately — potential distant micrometastatic disease with chemotherapy or local disease with surgery. In an era in which optimal chemotherapeutic regimens still have a 30%–40% nonresponse rate, early local therapy appears to be a more attractive concept.
Footnotes
This article has been peer reviewed.
Competing interests: None declared.
References
- 1.Sternberg CN, Collette L. What has been learned from meta-analyses of neoadjuvant and adjuvant chemotherapy in bladder cancer? BJU Int 2006;98:487-9. [DOI] [PubMed] [Google Scholar]