While adjuvant chemotherapy following radical cystectomy is known to improve outcomes and increase time to recurrence in patients with bladder cancer, no prospective trials have evaluated the effectiveness of adjuvant chemotherapy in patients with adverse pathologic features who received neoadjuvant chemotherapy prior to surgery. In an observational cohort study of patients with pT3/T4 or pN bladder cancer in the National Cancer Database, adjuvant chemotherapy in patients who received neoadjuvant chemotherapy was shown to be associated with an overall survival (OS) benefit compared to patients who did not receive adjuvant chemotherapy.
The study evaluated outcomes in 788 patients who received neoadjuvant chemotherapy and radical cystectomy followed by either adjuvant chemotherapy or observation. At a 6-month conditional landmark, patients who received adjuvant chemotherapy had an estimated OS of 29.9 months compared to 24.2 months for those who did not receive adjuvant chemotherapy (HR 0.78, P = .046). Estimated five-year OS was 36.8% versus 24.7% with and without adjuvant chemotherapy, respectively. The benefit for adjuvant chemotherapy was less significant in older patients. Gender, comorbidities, disease stage, and surgical margin status did not impact the benefit of adjuvant chemotherapy.
The investigators concluded that this analysis supports the efficacy of adjuvant chemotherapy in patients with pT3/T4 or pN bladder cancer who received neoadjuvant chemotherapy prior to radical cystectomy. Recognizing the limitations of an observation analysis, the authors indicated that this should be further investigated in a randomized, prospective clinical trial to identify specific treatment sequence that would provide the greatest survival benefit.