Chemotherapy for muscle-invasive bladder cancer treated with definitive radiotherapy: persisting uncertainties.

Radical cystectomy for invasive bladder cancer remains the standard of care in many parts of the world, including North America and many parts of Europe; however, a large body of international experience from single institutions and cooperative groups indicates satisfactory results with bladder-sparing approaches in appropriately selected patients. Overall, selective bladder preservation with trimodality therapy, consisting of transurethral resection of the bladder tumor, radiation, and chemotherapy, can achieve complete response rates of 70%, long-term survival rates of 40-50%, and survival rates with an intact bladder of 30-45%. Neoadjuvant chemotherapy followed by radiotherapy might provide up to 5% additional long-term absolute survival benefit compared with radiotherapy alone, although the studies to support this are not appropriately powered. Concomitant chemoradiation provides high response rates and disease control, although the level of evidence for this approach and the follow-up data are even less robust than those for neoadjuvant chemotherapy. Although direct comparison of surgically based and radiotherapy-based approaches would be very useful, it is highly unlikely that such a trial could ever be completed among the patients treated by the clinicians who routinely deal with invasive bladder cancer.