Conclusions
Bladder cancer is a chemosensitive disease, and systemic chemotherapy plays a role in its management. Cisplatin-based combination chemotherapy prolongs survival in the metastatic setting, and methotrexate, vinblastine, doxorubicin, and cisplatin or combination gemcitabine/cisplatin is the current standard of care. However, long-term survival in patients with metastatic disease is rare, and treatment is still palliative in nature. Combination chemotherapy that is not platinum based is recommended for patients who are ineligible for cisplatin therapy. Although carboplatin should not be substituted for cisplatin in fit patients, it may be considered in those who are ineligible for cisplatin. No approved second-line chemotherapy for metastatic bladder cancer exists, and response rates with available agents are variable.
The role of neoadjuvant cisplatin-based combination chemotherapy has been extensively evaluated and is associated with a modest but significant survival benefit. However, this is more pronounced in patients with high-risk disease, and a strong need exists to utilize this therapy. Studies with molecular markers and novel agents are needed to further improve outcomes in this setting and offer tailored therapy to patients based on risk stratification according to tumor type. The achievement of pathological complete response (pT0) with neoadjuvant chemotherapy has strong prognostic significance and may represent an alternate clinical end point for clinical trials. Although robust data are lacking for the use of chemotherapy in the adjuvant setting after cystectomy, it may be considered in patients who are at high risk for relapse. Unlike other solid tumors, targeted therapy is not well established in bladder cancer, and a critical need exists to develop novel agents that complement or are an alternative to conventional chemotherapies.