- To understand the additional value of neoadjuvant systemic treatment for patients with urothelial cell cancer (UCC)
- To determine the optimal treatment regimen for individual patients
- To select patients with UCC for neoadjuvant systemic treatment
- To be aware of future developments
In this E-Learning module, the author argues that, based on the high level of evidence, cisplatin-based neoadjuvant chemotherapy with subsequent radical cystectomy is the current standard of care for cT2-T4aN0M0 muscle-invasive bladder cancer and needs to be considered for every patient in that setting.
Urothelial cell cancer (UCC) is a transitional cell cancer of the urinary tract including the bladder, ureter, urethra, and urachus. Tumours of the urinary bladder account for 90-95% of UCC and literature on neoadjuvant systemic treatment for UCC not originating from the bladder is very limited. Therefore, this E-Learning module is focused on bladder UCC.
A meta-analysis that evaluated the effect of neoadjuvant chemotherapy showed that platinum-based combination chemotherapy has a significant benefit on overall survival. Compared to the published meta-analyses, the survival is expected to be better in current practice, because of optimised cisplatin-based chemotherapy schedules, improved surgery with extended lymphadenectomy, and improved radiation techniques. Platinum-based combination chemotherapy also has a significant benefit on disease-free survival and pathologic complete response. However, in clinical practice, the majority of patients with resectable UCC do not receive neoadjuvant chemotherapy at all.
In the following chapter the author explains that there is not a high level of evidence for adjuvant therapy, as randomised trials in the adjuvant setting are incomplete or underpowered. However, it is likely that high-risk patients (e.g. those with extravesical disease) who have not received neoadjuvant chemotherapy may benefit most from adjuvant chemotherapy.
In terms of schedule selection, the author underlines that there is only high-level evidence for neoadjuvant chemotherapy consisting of 4 cycles of cisplatin-based combinations, including accelerated M-VAC or gemcitabine-cisplatin regimens with the latest one being associated with less toxicity.
The module ends with the elaboration of future perspectives. Ongoing and future clinical trials may evaluate whether neoadjuvant systemic therapy in UCC can be improved by checkpoint inhibitors, inhibitors of VEGF signalling, FGFR3 inhibitors and other strategies. As the treatment options for patients with UCC are expanding, participation in clinical trials is highly recommended.
This E-Learning module was published in 2018 and expired in 2020.
The author has reported no conflicts of interest