Neoadjuvant chemotherapy in invasive bladder cancer: a systematic review and meta-analysis

Background Controversy exists as to whether neoadjuvant chemotherapy improves survival in patients with invasive bladder cancer, despite randomised controlled trials of more than 3000 patients. We undertook a systematic review and meta-analysis to assess the effect of such treatment on survival in patients with this disease. Methods We analysed updated data for 2688 individual patients from ten available randomised trials. Findings Platinum-based combination chemotherapy showed a significant benefit to overall survival (combined hazard ratio [HR] 0•87 [95% CI 0•78–0•98, p=0•016]; 13% reduction in risk of death; 5% absolute benefit at 5 years [1–7]; overall survival increased from 45% to 50%). This effect was observed irrespective of the type of local treatment, and did not vary between subgroups of patients. The HR for all trials, including those using single-agent cisplatin, tended to favour neoadjuvant chemotherapy (HR=0•91, 95% CI 0•83–1•01) although this tendency was not significant (p=0•084). Although platinum based combination chemotherapy was beneficial, there was no evidence to support the use of single-agent platinum; indeed, there was a significant difference in the effect between these groups of trials (p=0•044). Interpretation This improvement in survival encourages the use of platinum-based combination chemotherapy for patients with invasive bladder cancer.