Contemporary use of perioperative cisplatin-based chemotherapy in patients with muscle-invasive bladder cancer

Background: Level I evidence indicates that neoadjuvant cisplatin-based chemotherapy, in combination with radical cystectomy (RC), is associated with a significant survival advantage for patients with muscle-invasive bladder cancer. Despite this, neoadjuvant chemotherapy is not uniformly used. Our objective was to determine the patterns of utilization of neoadjuvant chemotherapy in patients undergoing RC for muscle invasive bladder cancer in a contemporary cohort in a tertiary care center. Methods: A retrospective review was performed of patients with bladder cancer who underwent RC between 2003 and 2008 at our institution. Clinical stage, pathologic stage, renal function, and perioperative chemotherapy treatments were tabulated. Primary outcome measures were the type and use of neoadjuvant chemotherapy among eligible patients. Secondary measures were the utilization patterns of adjuvant chemotherapy, renal function, pathologic outcomes, and disease specific and overall survival. Reasons for nonutilization of chemotherapy were also examined. Results: Among 238 patients who underwent RC for bladder cancer, 145 had a preoperative clinical stage ≤T2. Only 17% (25 of 145) of these patients received cisplatin-based neoadjuvant chemotherapy. The renal function was adequate (CrCl > 60 ml/min) in 97 (67%) of these patients. Patients who received neoadjuvant chemotherapy had higher p0 rates (29% vs 8%) than patients who did not receive neoadjuvant therapy. Advanced patient age, comorbidities, concerns over toxicity of chemotherapy, and the modest nature of benefit from neoadjuvant chemotherapy may explain why this treatment is not often used. Conclusions: Despite level I evidence, neoadjuvant cisplatin-based chemotherapies continue to be underutilized in the management of bladder cancer, even at a high-volume tertiary center. A prospective evaluation of management choices, including the patient and physician factors involved in the use of perioperative cisplatin-based chemotherapy in bladder cancer, is indicated.