Choice of adjuvant systemic therapy for patients with high-risk muscle-invasive urothelial carcinoma of the bladder

ECOG: Eastern Cooperative Oncology Group; NYHA: New York Heart Association; MVAC: methotrexate, vinblastine, doxorubicin, and cisplatin.
* High-risk disease at cystectomy is defined as either no prior neoadjuvant cisplatin-based chemotherapy with pathologic (p) T3-T4a and/or node-positive disease; or prior neoadjuvant cisplatin-based chemotherapy with pathologic (yp) T2-T4a and/or node-positive disease.
¶ For further details on eligibility for cisplatin-based chemotherapy, refer to UpToDate content on adjuvant therapy for muscle-invasive urothelial carcinoma of the bladder.
Δ Any of these regimens are appropriate for most patients. Some clinicians prefer gemcitabine plus cisplatin over MVAC regimens due to a better toxicity profile. However, others prefer MVAC regimens for fit patients, extrapolating from data suggesting a survival benefit for MVAC in the neoadjuvant setting. Since the use of adjuvant chemotherapy is controversial, patients may alternatively choose observation or clinical trial enrollment. For patients who choose adjuvant systemic therapy, we initiate treatment as soon as surgical recovery permits, typically around six to eight weeks postoperatively, and no later than three months after radical cystectomy.
◊ Patients who are ineligible for or do not meet indications for adjuvant immunotherapy may be offered observation after cystectomy or clinical trials. We do not suggest the use of adjuvant chemotherapy as data are limited for this approach.