Editing Muscle-Invasive Bladder Cancer (section)

==== Adjuvant ====
* '''Patients with pT3-T4 or N+ disease are at high risk for failure following cystectomy and can be offered adjuvant chemotherapy''' to treat micrometastatic disease and to improve survival

===== Advantages =====
# '''Allows for immediate local treatment''' with cystectomy and avoids any delay in treatment in patients with chemotherapy-resistant tumors
# '''Avoids overtreatment'''; the availability of final pathology also allows clinicians to select patients at the highest risk for failure who are most likely to benefit, while sparing those who are less likely to progress from the side effects of systemic chemotherapy.

===== Disadvantages =====
* '''Often difficult or impossible for patients to undergo systemic therapy following cystectomy''' secondary to surgical deconditioning, deteriorating renal function, or perioperative complications
** ≈24-52% of patients have renal function deterioration that makes them ineligible to receive AC postoperatively depending on the criteria used.
** '''Postoperative complications may exclude ≈30% of patients who may have been eligible from receiving AC postoperatively'''

===== Evidence =====
* No single phase III trial has demonstrated an overall survival benefit with AC compared to observation
* '''2014 meta-analysis''' of 9 trials involving 945 patients '''comparing AC to standard of care found a 9% absolute survival benefit at 3 years.''' However, there were major deficiencies in the trials included such as small sample sizes, early closure of trials, limitations in statistical analysis, and differences in the way disease-free survival was defined.
** [https://pubmed.ncbi.nlm.nih.gov/24018020/ Leow, Jeffrey J., et al.] "Adjuvant chemotherapy for invasive bladder cancer: a 2013 updated systematic review and meta-analysis of randomized trials." European urology 66.1 (2014): 42-54.

===== Indications =====

====== AUA ======

* '''2020 AUA Muscle-Invasive Bladder Cancer Guidelines'''
** '''<span style="color:#ff0000">Eligible patients who have not received cisplatin-based NAC and have non-organ confined (pT3/T4and/or N+) disease at cystectomy should be offered adjuvant cisplatin-based chemotherapy (same as CUA)</span>'''

===== NAC vs. Adjuvant Chemotherapy =====
* '''The available evidence suggests perioperative chemotherapy does confer a survival benefit for bladder cancer patients, with stronger evidence available in the neoadjuvant approach'''. The optimal approach and benefit to systemic chemotherapy in the adjuvant setting remains incompletely defined, and may remain unanswered based on the difficulty with patient accrual in past trials