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Decreased Overall and Bladder Cancer-Specific Mortality with Adjuvant Chemotherapy After Radical Cystectomy: Multivariable Competing Risk Analysis

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Froehner M., Koch R., Heberling U., Novotny V., Oehlschlaeger S., Hübler M., Baretton G.B., Hakenberg O.W., Wirth M.P.

European Urology 2015

Adding chemotherapy to radical cystectomy (RC) may improve outcome. Neoadjuvant treatment is advocated by guidelines based on meta-analysis data but is severely underused in clinical practice. Adjuvant treatment of patients at risk could be an alternative. We analyzed a sample of 798 patients who underwent RC between 1993 and 2011 for high-risk superficial or muscle-invasive urothelial or undifferentiated bladder cancer, of which 23% received adjuvant cisplatin-based chemotherapy and %5 received neoadjuvant chemotherapy. The use of adjuvant chemotherapy was an independent predictor of decreased overall mortality (hazard ratio [HR]: 0.50; 95% confidence interval [CI], 0.38-0.66; p <. 0.0001) and bladder cancer-specific mortality (HR: 0.71; 95% CI, 0.52-0.97; p = 0.0321), but it was not associated with competing mortality. Similar figures were obtained when analyzing the number of cisplatin-containing cycles administered or when restricting the analysis to patients with lymph node-positive or extravesical but lymph node-negative disease, suggesting a mortality-reducing treatment effect after adjusting for several patient- and tumor-related confounders. Future trials should directly compare the concepts of neoadjuvant and adjuvant application of chemotherapy in candidates for RC. Patient summary: Adjuvant chemotherapy may decrease overall and bladder cancer-specific mortality after radical cystectomy (RC). Future trials should directly compare the concepts of neoadjuvant and adjuvant application of chemotherapy in candidates for RC. Adjuvant cisplatin-based chemotherapy offered to patients at risk was associated with decreased overall and bladder cancer-specific mortality after adjusting for several patient- and tumor-related confounders in a routine clinical setting, with a greater effect in extravesical node-negative disease. Future trials should directly compare the concepts of neoadjuvant and adjuvant application of chemotherapy in candidates for radical cystectomy.

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