Contrary to treatment guidelines for high-risk bladder cancer, chemotherapy before or after surgery is not commonly used in routine clinical practice.

Clinical trials have shown that survival is improved in patients with muscle-invasive bladder cancer who are given chemotherapy before surgery. There is less evidence about whether chemotherapy after surgery also improves survival.

To investigate the use of peri-operative chemotherapy in this disease, Christopher Booth, MD, FRCPC, of the Queen’s University Cancer Research Institute in Kingston, Ontario, Canada, examined records pertaining to all 2,944 patients who had surgery for high-risk bladder cancer in Ontario between 1994 and 2008.

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Use of chemotherapy before surgery remained stable (an average of 4% of patients) during the study period, which is surprising given the evidence that this is a standard of care that has been demonstrated to improve survival. The use of chemotherapy after surgery increased over time: 16% of patients in 1994 to 1998, 18% in 1999 to 2003, and 22% in 2004 to 2008. Study results showed that use of chemotherapy after surgery was associated with better survival. The findings were published in Cancer (2014; doi:10.1002/cncr.28510)

“Results from our study demonstrate that chemotherapy given after surgery improves patient survival—probably on the same order of magnitude as chemotherapy before surgery,” said Booth. “Patients having surgery for bladder cancer should have chemotherapy, either before or after surgery. Efforts are needed to improve uptake of this treatment, which appears to be vastly underutilized.”

The study found that the use of chemotherapy, whether before or after surgery, was substantially lower in older patients, and that its use had a strong association with poor prognosis, as determined by pathology. The study also noted substantially lower 5-year overall survival for patients who received chemotherapy before (25% 5-year overall survival) or after (29% 5-year overall survival) surgery than has been reported in the relevant clinical trials.