Two intergroup trials and a meta-analysis have shifted the treatment for muscle-invasive bladder TCC towards the use of neoadjuvant chemotherapy, with between 13% and 24% reduction in mortality.8-10 Compared with local treatment alone, neoadjuvant cisplatin-based chemotherapy was associated with a 14% relative decrease in the risk of death and a 5% absolute survival benefit at 5 years. Many oncologists substitute standard-dose MVAC for 12 weeks (3 cycles) in muscle-invasive TCC of the urothelium with either GC for 12 weeks or high-dose MVAC with granulocyte-colony stimulating factor for 4 cycles (8 weeks). This recommendation is based on the results of 2 randomized controlled studies performed in patients with metastatic disease, which showed that GC and high-dose MVAC are equally effective but less toxic than standard-dose MVAC.11,12
- Neoadjuvant chemotherapy with MVAC, followed by radical cystoprostatectomy and lymphadenectomy.
9. Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer [published erratum appears in N Engl J Med 2003;349:1880]. N Engl J Med 2003;349:859-66.
10. Advanced Bladder Cancer Overview Collaboration. Neoadjuvant chemotherapy for invasive bladder cancer. Cochrane Database Syst Rev 2005;(2):CD005246.
11. von der Maase H, Hansen SW, Roberts JT, et al. Gemcitabine and cisplatin versus methotrexate, vinblastine, doxorubicin, and cisplatin in advanced or metastatic bladder cancer: results of a large, randomized, multinational, multicenter, phase III study. J Clin Oncol 2000;18:3068-77.
12. Sternberg CN, de Mulder P, Schornagel JH, et al; EORTC Genito-Urinary Cancer Group. Seven-year update of an EORTC phase III trial of high-dose intensity M-VAC chemotherapy and G-CSF versus classic M-VAC in advanced urothelial tract tumors. Eur J Cancer 2006;42:50-4.
8. Neoadjuvant cisplatin, methotrexate, and vinblastine chemotherapy for muscle-invasive bladder cancer: a randomised controlled trial. International Collaboration of Trialists [published erratum appears in Lancet 1999;354:1650]. Lancet 1999;354:533-40.
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