Neoadjuvant chemotherapy in bladder cancer

The use of neoadjuvant chemotherapy is an important element in the management of advanced bladder cancer. While definitive surgical management of locally advanced disease remains the gold standard of treatment, evidence over the years has repeatedly and consistently demonstrated the survival benefits of presurgical systemic chemotherapy. Incorporation of neoadjuvant chemotherapy into the treatment of urothelial carcinoma is based upon the following assumptions: administering chemotherapy prior to surgery may render tumors resectable through down-staging; chemotherapy can eradicate micrometastatic disease already present at the time of diagnosis, thereby reducing the risk of local and distant recurrence and improving overall survival; and, the preoperative setting represents a window of opportunity for the safe delivery of the recommended doses of chemotherapy. In this review, the authors examine the evidence for chemotherapy in the neoadjuvant setting and discuss ongoing advances in the field.