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Selection of adjuvant systemic therapy in high-risk muscle-invasive urothelial carcinoma of the bladder

Selection of adjuvant systemic therapy in high-risk muscle-invasive urothelial carcinoma of the bladder
Management is complex for patients with high-risk muscle-invasive urothelial carcinoma of the bladder at cystectomy. For such patients, the selection of adjuvant therapy is based upon whether neoadjuvant chemotherapy was previously received or not prior to radical cystectomy, among other clinical factors. Neoadjuvant chemotherapy followed by radical cystectomy remains the preferred approach since it is associated with improved overall survival, but some patients may still be at high risk for recurrence after cystectomy. Other patients may receive initial treatment with radical cystectomy rather than neoadjuvant chemotherapy, and adjuvant therapy may be reserved for those at high risk for recurrence. Enrollment in clinical trials is encouraged, where available.

ECOG: Eastern Cooperative Oncology Group; MVAC: methotrexate, vinblastine, doxorubicin, and cisplatin; NYHA: New York Heart Association.

* High-risk disease at cystectomy is defined as either no prior neoadjuvant cisplatin-based chemotherapy with pathologic (p) T3-T4a and/or node-positive disease; or prior neoadjuvant cisplatin-based chemotherapy with pathologic (yp) T2-T4a and/or node-positive disease.

¶ Any of these regimens are appropriate for most patients. Some clinicians prefer gemcitabine plus cisplatin over dose-dense MVAC due to a better toxicity profile. However, others prefer dose-dense MVAC regimens for fit patients, extrapolating from data suggesting a survival benefit for this regimen in the neoadjuvant setting. For patients who choose adjuvant chemotherapy, we initiate treatment as soon as surgical recovery permits, typically around six to eight weeks postoperatively, and no later than three months after radical cystectomy.

Δ Patients who are ineligible for adjuvant immunotherapy may be offered clinical trials. We do not suggest the use of adjuvant chemotherapy as data are limited for this approach.
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