A systematic overview of chemotherapy effects in urothelial bladder cancer

A systematic review of chemotherapy trials in several tumour types was perf ormed by The Swedish Council of Technology Assessment in Health Care (SBU). The procedures for the evaluation of the scientific literature are describ ed separately (Acta Oncol 2001; 40: 155-65). This synthesis of the literatu re on chemotherapy for urothelial bladder cancer is based on 234 scientific reports including two meta-analyses, 75 randomised studies and 143 other p rospective studies, and totally comprising 31974 patients. The conclusions reached can be summarised into the following points: Intravesical chemotherapy administered in an adjuvant setting to transureth ral resection (TUR-B) of superficial tumour reduces short-term (one to thre e years) recurrence rate by approximately 20%. After a median follow-up of eight years, 8% fewer recurrences were seen after intravesical chemotherapy . Long-term maintenance instillation chemotherapy (> 1 year) does not further increase the recurrence-free interval nor the long-term recurrence rate wh en compared with immediate postoperative short-term intravesical chemothera py. The majority of studies on intravesical Bacillus Calmette-Guerin (BCG) vs i ntravesical chemotherapy show superior protection from tumour recurrence fo r BCG. Despite prolongation of the disease-free survival, adjuvant intravesical ch emotherapy has, in the majority of studies, no apparent lone-term impact on the evolution of superficial into muscle invasive bladder cancer. There are no data showing a survival benefit from adjuvant intravesical che motherapy. Chemotherapy with cisplatin-based regimens induce objective tumour response in at least 50% of patients with metastatic disease. A prolonged disease-f ree and overall survival (median two to three months) is seen in patients t reated with visplatin-based polychemotherapy compared with patients treated with cisplatin alone or less intensive chemotherapy. With the exception of one randomised study, there are no conclusive data on possible survival benefit for patients with muscle-invasive bladder cancer treated with neoadjuvant chemotherapy prior to cystectomy or radiotherapy. Although the results from use of adjuvant chemotherapy after surgery or cur ative radiotherapy obtained are promising, the small studies performed lack statistical power and, hence, there is insufficient data to make any concl usion regarding a possible survival benefit from adjuvant chemotherapy. A growing body of data indicate that bladder preservation can be achieved b y multi-modality approach in selected patients and that survival in these i s similar to that seen after radical cystectomy, but randomised trials are still lacking.