Neoadjuvant chemotherapy (NAC) before radical cystectomy — the gold standard treatment for muscle-invasive bladder cancer (MIBC) — is underused in older patients with cT2-4a muscle-invasive bladder cancer (MIBC) despite evidence that they benefit from the treatment, investigators revealed during the AUA2021 Virtual Experience.

Guidelines from the National Comprehensive Cancer Network (NCCN) recommend that patients with cT2-4a receive neoadjuvant cisplatin-based chemotherapy before radical cystectomy (RC). Bladder cancer is typically diagnosed at older ages (median 73 years). A landmark 2003 study published in the New England Journal of Medicine found longer median survival among older patients treated with NAC than without: 61 vs 30 months.

“Patients of advanced age who are candidates for radical cystectomy should be offered NAC,” Natasza Posielski, MD, of Virginia Mason Medical Center in Seattle, Washington, and colleagues concluded in a poster presentation.

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Using the National Cancer Database 2006 to 2017, her team identified 70,911 adults with cT2-4a MIBC, of whom 14,018 were aged 70 years and older and underwent RC. After propensity weighting, fewer patients older than 70 years than younger received NAC prior to RC: 7.2% vs 20.9%, respectively. Older age independently predicted significant 48% lower odds of receiving NAC before RC.

Private insurance, higher income, high school completion, lower Charlson Comorbidity Index, higher clinical T stage, pelvic lymph node dissection, and recent diagnosis predicted NAC receipt before RC.  

Many elderly patients are not offered NAC because of concern regarding physiologic reserve and postoperative complications, Dr Posielski’s team noted. Yet perioperative complications were comparable for older adults who did and did not receive NAC prior to RC, she said. Length of stay (8.5 vs 9.6 days), readmission within 30 days (8.6% vs 10.6%), 30-day mortality (1.5% vs 3.1%) and 90-day mortality (4.9% vs 7.7%), and overall survival (43.8% vs 37.5%) all slightly favored the NAC vs no-NAC group. The NAC group had significant 34%, 38%, and 28%, reduced odds of longer hospitalization, and 30- and 90-day morality, respectively.


Posielski N, Jung N, Koenig H, Ho O, Flores JP, Porter C. Use of neoadjuvant chemotherapy in elderly patients with muscle invasive bladder cancer: a population-based study, 2006-2017. Presented at: AUA2021 Virtual Experience held September 10-13, 2021. Poster MP13-14.

Barton Grossman H, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med. 2003; 349:859-866. doi:10.1056/NEJMoa022148