Neoadjuvant chemotherapy for muscle-invasive bladder cancer (MIBC) is the standard in cisplatin-eligible patients and should be given for MIBC prior to radical cystectomy.
Neoadjuvant chemotherapy for high-risk upper tract urothelial cancer (UTUC) is still controversial and lacking level 1 evidence. Extrapolation from MIBC data and the high rate of renal insufficiency after radical nephroureterectomy resulting in cisplatin-ineligibility, make neoadjuvant chemotherapy (NAC) for high-risk UTUC a rational approach.
Checkpoint inhibitors (CPI) and other targeted therapies in combination with development of predictive biomarkers have the potential to change neoadjuvant treatment strategies in patients with urothelial cancer and allow individual strategies for systemic therapies rather than the currently used “one-fits-all” principle.
Overview of current treatment approach
- MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin)
- Dose-dense MVAC (ddMVAC) with granulocyte colony-stimulating factor (G-CSF) support and double the dose-intensity of cisplatin and doxorubicin, while reducing the dose of methotrexate and vinblastine by one third compared to classic MVAC
- GC (gemcitabine, cisplatin)
- CMV (cisplatin, methotrexate, and vinblastine)