The latest literature reports that preoperative neoadjuvant chemotherapy for bladder cancer can increase overall 5-year survival rates for patients with bladder tumors by 5 percent. American experts compare that 15,000 bladder cancer patients die each year in the United States, and if the 5-year survival rate were increased by 5%, it would mean that 750 bladder cancer patients would be alive each year, or that 3,750 bladder cancer patients would be alive over a 5-year period, and these people and those who love them would consider preoperative neoadjuvant chemotherapy for bladder cancer to be worthwhile.
In general, although patients with locally advanced bladder cancer can be treated with radical cystectomy, this group of patients are at risk of metastasis, and it has been reported that in patients with stage T3 bladder cancer, 56% of local recurrences infiltrate the peri-bladder tissue and more commonly distant metastases, mainly due to the presence of unexplained micro-metastatic lesions. It has been demonstrated that radiation therapy after cystectomy does not improve prognosis, so systemic chemotherapy is known as a treatment option for patients with bladder tumors, and chemotherapy is divided into preoperative chemotherapy (also called neoadjuvant chemotherapy) and postoperative chemotherapy (called adjuvant chemotherapy).
The New England Journal reported the results of the neoadjuvant chemotherapy study: patients with muscle-infiltrating bladder cancer (T2-T4a) were randomized to either the infiltrating superficial muscle layer group (T2) or the infiltrating deep muscle layer or surrounding group (T3 or T4a), and also, grouped by age greater or less than 65 years. The pre-surgical chemotherapy regimen (M-VAC) was methotrexate, vincristine, adriamycin, and cisplatin for 3 cycles of chemotherapy, followed by radical cystectomy. The results of the 11-year follow-up comparing the treatment efficacy of the surgery alone group and the preoperative chemotherapy plus surgery combination group revealed that: the surgery alone group had a mean follow-up of 8.4 years and 100% of patients died; the preoperative chemotherapy plus surgery combination group had a mean follow-up of 8.7 years and 90% of patients died. The average survival was 46 months in the surgery alone group and 77 months in the preoperative chemotherapy plus surgery group. Patients in the combined preoperative chemotherapy plus surgery group had a higher rate of tumor-free bladder specimens (38%) than the tumor-free rate in the surgery alone group (15%), which was responsible for the difference in survival time between the two, while stratified analysis excluded the effects of tumor infiltration depth and age factors on treatment outcome.
Thus, preoperative chemotherapy, also known as neoadjuvant chemotherapy, plus surgery for patients with locally advanced bladder tumors is safer, reduces tumor residual in cystectomy specimens and improves prognosis compared to cystectomy alone. Neoadjuvant chemotherapy with a combination of four drugs can be applied to patients with locally advanced bladder cancer who will undergo radical cystectomy, but care needs to be taken to: select patients with good renal function, closely monitor chemotherapy toxicities, and intervene promptly in the event of serious side effects.
However, even in the medically advanced United States, neoadjuvant chemotherapy is applied to less than 2% of patients with muscle-infiltrating bladder cancer. Experts analyze the following misunderstanding factors that prevent the widespread use of preoperative neoadjuvant chemotherapy for bladder cancer: 1. Patients with local and small volume invasive bladder cancer prefer complete resection of the bladder and lymph node dissection for treatment effect.
2, Chemotherapy may alter the initial pathological staging results.
3.Chemotherapy prolongs eventual surgery and leads to disease progression in patients with bladder cancer unresponsive to chemotherapy.
4.Chemotherapy increases perioperative complications.
5.Chemotherapy is associated with morbidity and possibly mortality, increasing costs and patient inconvenience.
6, The benefit of neoadjuvant chemotherapy is limited, increasing the survival rate of bladder cancer patients by only 5% at 5 years.
7, Patient-side opinions and complications limit the application of neoadjuvant chemotherapy.
8, Narrow clinical factors, such as tumor size, hydronephrosis, lymphovascular infiltration, and mixed histologic pathologic findings, clearly indicate patients with bladder tumors at high risk of metastasis as an indication for neoadjuvant chemotherapy.