Neoadjuvant Chemotherapy Plus Cystectomy vs Cystectomy Alone for cT0 Muscle-invasive Bladder Cancer After Maximal TURBt: Multicentre Prospective Randomized Controlled Trial

Radical Cystectomy (RC) is considered the reference option for treatment of urothelial muscle invasive bladder cancer (MIBC). However, RC alone has been reported 5-year survival in about 50% of patients. Therefore, to improve survival outcomes in patients with non-metastatic MIBC, cisplatin-based neoadjuvant chemotherapy (NAC) has been introduced. On the one hand, major tolerability, higher patient compliance and lower burden of micrometastatic disease are listed as potential advantages of administering NAC before planned definitive surgery. Several phase III randomized controlled trials (RCTs) reported the potential survival benefit of NAC administration.

Moreover, the updated analysis of a large phase III RCT, globally including all patients with muscle invasive bladder cancer from T2 to T4, regardless of post transurethral resection of bladder tumor (TURBt) tumor volume, with a median follow-up of 8-yrs confirmed previous results providing additional findings:

• 16% reduction in mortality risk;
• improvement in 10-yr survival from 30% to 36% with NAC;
• Benefit with regard to distant metastases;
• the addition of NAC provided no benefit for locoregional control and locoregional disease free survival (DFS).

On the other hand, the possibility to predict patients' sensitivity to chemotherapy is still limited. Therefore, the delay in performing RC and the theoretical impact of NAC on surgical morbidity are considered significant limitations to a routine administration of neoadjuvant treatments. As a result, it is growing the interest at improving selection clinical criteria to identify the ideal candidates to NAC, in order to obtain the maximal survival benefit of NAC, minimizing its possible disadvantages. Reliable predictive markers and molecular tumour profiling might guide the use of NAC in the future, but nowadays they are not currently used in clinical practice.

Despite the evidence supporting the use of NAC, its routine administration is still limited. The risk of unresponse after NAC, with the consequent delay in surgical treatment, and the possible impact on surgical morbidity after RC, are the major limitations to the wide administration of NAC. Previous evidences supported the use of NAC in patients with T2 to T4a BCa, regardless of tumor volume at the time of NAC. It is growing the interest on a tailored approach to treat genitourinary cancer, therefore it is needed much more efforts to select which patient will benefit most from NAC rather than an early RC. To answer this question, it is needed to selectively perform RCTs aiming to test specific treatments in equally specific patients. The primary objective of the trial is to demonstrate the non-inferiority of RC alone versus NAC plus RC on survival outcomes of patients with a diagnostic TURBt of non-metastatic muscle invasive bladder cancer (MIBC) (T2-T4 N0 M0) and non-radiologic or endoscopic residual tumor after a maximal TURBt (cT0). Survival benefits of cisplatin-based NAC were already described. The SWOG trial 3 reported a 33% reduction of estimated risk of death in the NAC plus cystectomy group compared to RC alone.